Cleanup efforts following the devastating Eaton and Palisades fires are underway, but an ongoing concern is swimming pools in the two burn zones, many of which contain stagnant water that has become a breeding ground for mosquitoes that can carry diseases.

In the region affected by the Eaton fire, officials responsible for mosquito control say they do not have the funds needed to provide sufficient treatment for all the pools that are now possible mosquito hothouses. That has sparked public health concerns in an area that has recently seen spikes in locally acquired cases of dengue fever, a potentially fatal mosquito-borne disease.

In mid-May, the San Gabriel Valley Mosquito and Vector Control District, which serves Altadena, Pasadena and Sierra Madre, identified some 1,475 pools in the burn zone as “nonfunctional” — meaning they contained stagnant water due to ash and debris, damaged equipment, or the homeowner’s inability to maintain the pool at the moment. Most of the pools are located in Altadena, and the district has so far been able to treat about half of them with pesticides.

The agency says it should be able to treat the other half with resources it will have available to it, but lacks the funding to provide the two follow-up applications experts say are needed to continue to stave off mosquito breeding throughout the year.

Indeed, officials found mosquitoes breeding in roughly 80% of the approximately 700 pools in the burn area that they treated with pesticides to date. A single swimming pool can become a breeding ground for as many as 3 million mosquitoes in one month.

“This is a public health concern. It will be a risk if it doesn’t get addressed,” said Anais Medina Diaz, spokesperson for the San Gabriel Valley vector control district, which spans 26 cities and unincorporated areas. Vector control districts are local agencies tasked with managing disease-spreading critters like mosquitoes.

Mosquitoes lay their eggs on or near stagnant water. When they hatch, the young develops in the water before emerging as a buzzing adult.

District officials have spent $307,000 to apply a pesticide treatment to about half of the 1,475 affected pools, mostly on the perimeter of the burn scar, Diaz said.

District officials had planned to use that money to respond to anticipated cases of dengue fever, a viral infection spread by invasive mosquitoes. Last year the district saw 11 locally acquired cases of dengue, more than anywhere else in the state.

The emergency reserves aren’t completely tapped, but the district needs to keep funds in its coffers in case disease does strike, Diaz said.

So district officials said they sent a request to the L.A. County Office of Emergency Management and the California Governor’s Office of Emergency Services for an additional $302,000 to cover the costs of an initial pesticide treatment for the more than 700 yet-untreated pools, and to pay for two follow-up treatments for all 1,475 pools throughout the coming year.

On Thursday, the state agency approved a portion of the request, said Pablo Cabrera, a spokesperson for the district. Details and dollar amounts were still being finalized, but district officials said it would be enough to apply pesticides to the pools that have yet to be treated. It would not cover the two subsequent treatments.

Vector control officials began treating the first round of pools in mid-March. Each pesticide treatment controls mosquito larvae for up to 90 days — so the treatment on those initial pools will wear off around mid-June, often the height of mosquito season. The plan is to finish up the remaining pools by the end of June.

Current resources will allow for “full control” of mosquito breeding through August, according to Cabrera. What comes next will depend on what sort of financial support the district will get moving forward.

“We would love to have this kind of funding to be able to carry out these additional treatments. That is what we want to do,” Diaz said. “But we were not set up in a way where we can cover this area and then continue to do our vector control work throughout the San Gabriel Valley.”

In a statement, Ed Chapuis, a spokesperson for the California Governor’s Office of Emergency Services, said that the state is providing resources for urgent treatments and will continue to work with the district. State and/or federal disaster assistance funding could potentially be tapped, he said.

The agency “will continue supporting the district to ensure no delay in their efforts to address public safety,” he said.

Officials with the county Office of Emergency Management said their role was only to connect the state and local agencies.

San Gabriel Valley district officials have requested that $500,000 be set aside in the state budget for mosquito-control efforts in 2026 and beyond. They’re also seeking reimbursement from the Federal Emergency Management Agency for expenses incurred while tackling the first batch of pools.

The district has enhanced surveillance of the burn area and will be as proactive in its approach as possible with the means it has, officials said.

Mosquitoes in the Palisades fire burn scar

Coastal communities that were in the path of January’s destructive Palisades fire are similarly contending with the issue of unmaintained pools.

A survey of the burn area revealed more than 1,700 parcels with a pool or spa where mosquitoes could breed, according to the Los Angeles County West Vector Control District. The district provides services to the western portion of the city of L.A., including Pacific Palisades, as well as the city of Malibu.

The pools need to be “drained and dry or clean and filtered” to prevent breeding, and some preliminary inspections have gone forward, said Aaron Arugay, executive director of the district, in an email. Some mosquito breeding was seen in the problem pools, and was treated, he said.

“Due to the number of parcels, this is going to be an ongoing project all season,” Arugay said.

It’s an unexpected task, but Arugay said he doesn’t anticipate issues with drawing from the district’s budget and reserves to cover the costs for the season. The plan is to bring on temporary seasonal staff to help out in the summer and fall.

What’s at stake

The region’s invasive mosquitoes, Aedes aegypti, were behind what public health officials deemed “unprecedented” local spread of dengue last year in Los Angeles County.

There were 14 local dengue cases in the county last year, and 11 of them were within the footprint of the San Gabriel Valley vector control district. Just two years ago, the state’s first known case of locally acquired dengue — in a Pasadena resident — occurred in the district.

Symptoms of dengue can include joint and muscle pain, severe headaches and bleeding under the skin. Last year, more than a third of L.A. County residents infected with the disease needed to be hospitalized, according to the L.A. County Department of Public Health.

Of particular concern right now are native Culex mosquitoes, which can transmit deadly West Nile virus, Diaz said. This species makes up the majority of the region’s mosquito population, and its season typically peaks earlier than Aedes mosquitoes.

West Nile can cause severe and potentially fatal brain inflammation, among other serious issues. There were 35 confirmed cases of West Nile virus in L.A. County in 2024, including 27 hospitalizations and two deaths, according to data from the L.A. County Department of Public Health.

Culex mosquitoes typically target birds rather than humans, and tend to be satisfied with one slurp of blood, making them comparatively less annoying than Aedes mosquitoes. The Aedes mosquito is known for biting ankles during the day, often striking multiple times in succession.

The Aedes aegypti species of mosquito arrived in California a little over a decade ago, and has since spread to more than a third of state’s counties. Vector control officials have sought to beat back the scourge, galvanized by the unhappy residents and fear of spiking disease that’s starting to be realized.

In recent years, a couple of local districts have rolled out pilot programs entailing the release of sterile male mosquitoes to drive the population down, a relatively new approach to tackling these mosquitoes.

Early data have shown promise, with a mosquito population reduction of nearly 82% in one study area in L.A County last year. (Males don’t bite, so they aren’t contributing to itchy welts or disease spread.)

The method appears to be catching on, and the San Gabriel Valley vector control district plans to launch a similar program next year, Diaz said.

The Greater L.A. County Vector Control District, which covers the largest portion of the county, is currently gauging whether its homeowners will pay up to $20 a year to expand its sterile male release program. Diaz said the San Gabriel Valley district will probably be seeking additional funding from its property owners in 2027.

Such efforts have taken on heightened urgency amid the rise in dengue. And as mosquito season has lengthened in recent years amid warming temperatures, some of the bloodsuckers now stick around until December in parts of the Southland.

On the plus side, recent lower temperatures have slowed the insects’ life cycle in the Eaton fire burn area, and mosquito abundance levels have been below average. But the mercury is poised to rise.

Former President Biden’s weekend announcement that he has an “aggressive” form of prostate cancer that has metastasized to his bone sparked the usual sympathy from supporters — and sharp suspicions among detractors.

The announcement comes amid fresh reporting on Biden and his inner circle hiding the degree to which his mental acuity was slipping during his presidency and campaign for reelection last year, and the advanced stage of his cancer drew immediate accusations from the right that the former president was also hiding problems with his physical health.

President Trump said he was surprised the cancer “wasn’t notified a long time ago,” suggested the public wasn’t being properly informed and said that “people should try and find out what happened.”

The Times spoke to six doctors who are experts in prostate cancer. They said the information Biden’s office has shared about his condition is indeed limited, but also that many of the assumptions being made publicly about the progression of such cancers, the tests that can screen for them and the medical guidelines for care among men of Biden’s advanced age — 82 — were simply off base.

The cancer

In its statement Sunday, Biden’s office said the former president was seen last week “for a new finding of a prostate nodule after experiencing increasing urinary symptoms,” and on Friday was “diagnosed with prostate cancer, characterized by a Gleason score of 9 (Grade Group 5) with metastasis to the bone.”

Dr. Mark Litwin, chair of UCLA Urology, said that description indicated Biden has a more advanced and aggressive form of prostate cancer than is diagnosed in most men, but that it was nonetheless “a very common scenario” — with about 10% of such cancers in men being metastatic at diagnosis.

Dr. Howard Sandler, chair of the Department of Radiation Oncology at Cedars-Sinai, agreed.

“It’s a little unusual for him to show up with prostate cancer that’s metastatic to bone at first diagnosis, but not extraordinary,” he said. “It happens every day to elderly men.”

That’s in part because of the nature of such cancer, the modern screening guidelines for older men, and the advanced treatment options for such cancer when it is found, the doctors said.

Prostate cancer in small, slow-growing amounts is prevalent among men of Biden’s age, whether it’s causing them problems or not. Most prostate cancers can be slowed even more dramatically — for years after diagnosis — with medical intervention to block testosterone, which feeds such tumors.

For those reasons, many doctors recommend men stop getting tested for prostate-cancer-related antigens, through what’s known as a PSA test, around age 70 or 75, depending on the individual’s overall health.

That advice is based in part on the idea that finding a slow-moving prostate cancer and deciding to act on it surgically or otherwise — which many alarmed patients are inclined to do when they get such news — can often lead to worse outcomes than the cancer would have caused if simply left alone. That includes impotence, incontinence and life-threatening infections.

Also, if an older patient does start experiencing symptoms and is found to have a more advanced prostate cancer, modern treatments are capable of stalling the cancer’s growth for years, the doctors said — often beyond the point when those patients are statistically likely to die from something else.

Even when older patients are tested and show somewhat elevated PSA levels, it is not always of immediate concern, and they are often told to just keep an eye on it, Litwin said. Simply put, doctors “typically don’t get too exercised about a diagnosis of prostate cancer in an 82-year-old,” he said.

Dr. Sunil Patel, a urologic oncologist and an assistant professor of urology and oncology within the Brady Urological Institute at the Johns Hopkins University School of Medicine, said that’s because the average life expectancy for an American man is under 85.

“And so most men at that time, at 75, they’re like, ‘OK, well, if it’s not going to kill me in the next 10 years, I’m going to leave it alone,’” Patel said. “That’s a really shared decision between the patient and the physician.”

When advanced, aggressive prostate cancers are found, as with Biden, the prognosis — and treatment plan — is of course different, the doctors said. “He is for sure going to need treatment,” Litwin said. “This is not the type that we can just observe over time like we often do.”

But that doesn’t mean Biden’s doctors dropped the ball earlier, he and others said.

The diagnosis

Biden’s office has not said whether he was receiving PSA screenings. A letter from Biden’s White House physician in February of last year made no mention of PSA testing, despite other recent presidents’ medical assessments including that information. Biden’s aides did not respond to requests for comment.

The doctors The Times spoke to had no special insight into Biden’s medical care, but said his diagnosis did not make them feel any less confident about the caliber of that care or suggest to them any nefarious intent to hide his condition.

For starters, “it would be considered well within the standard of care” for Biden to have forgone testing in recent years, given his age, Sandler said. “Certainly after 80.”

Litwin said he believes Biden probably was still tested, given his position, but that doesn’t mean he was necessarily hiding anything either. Some forms of aggressive prostate cancer don’t secrete antigens into the blood at levels that would be flagged in a PSA test, while others can grow and even metastasize rapidly — within a matter of months, and between routine annual screenings, he said.

Patel said he has personally found “very aggressive disease” in patients who had relatively normal PSA levels. “I don’t think anyone can blame anyone in terms of was this caught too late or anything like that,” he said. “This happens not too infrequently.”

Dr. Alicia Morgans, associate professor of medicine at Harvard Medical School, a genitourinary medical oncologist and the director of the Survivorship Program at the Dana-Farber Cancer Institute, agreed. Even if a patient is diligent about getting screened annually, “there will be some cancers that arise between screening tests,” she said.

Morgans said things gets even more complicated as men get older, when their PSA number may increase and start getting monitored before it is considered a clear indicator of cancer.

“Maybe it’s up a while. It was not cancer before, it hasn’t really changed that much. Now it has become cancer. It’s not the fault of anyone,” she said. “You can do everything right and things like this can happen.”

The treatment

Biden’s office said his cancer appeared “to be hormone-sensitive, which allows for effective management.”

The doctors The Times spoke to were relatively bullish about Biden’s short-term — and even medium-term — prognosis. “It’s not curable, but it’s highly treatable,” Morgans said.

“Without meaning to sound glib, there’s never been a better time to have metastatic prostate cancer in the history of medicine,” Litwin said — in part thanks to Biden’s own cancer “moonshot” initiative and the funding it sent to institutions such as UCLA, which has helped develop new drugs.

“There are numerous, very effective treatments for a patient in his situation,” Litwin said.

The standard and most likely course of care for Biden will be ADT, or androgen deprivation therapy, which involves a pill or shot that will shut down testosterone production, the doctors said.

“Now, an 82-year-old doesn’t have the same testosterone production as a 22-year-old anyway, so there’s not that far to go. But we shut it off,” Litwin said. “And by shutting it off, it cuts out the principal hormone that feeds the prostate cancer. That alone can be very, very effective.”

Dr. Geoffrey Sonn, urologic oncologist and associate professor of urology at Stanford Cancer Center, said Biden’s cancer is serious, but the ADT treatment “will make prostate cancer cells shrink down, stop growing, at least temporarily, in the vast majority of guys.”

“That is, it’s not a permanent fix, in that those cells will eventually figure out a way to grow even with low levels of testosterone,” Sonn said. “But that can take several years, and sometimes longer.”

Recent studies have shown that adding additional medications to an ADT regime can extend life even further, Sonn said, to “four, five, seven, 10” years or more after a metastatic prostate cancer diagnosis.

Dr. Mihir Desai, a urologist with Keck Medicine of USC, said with modern advancements, prostate cancer is just different than other cancers.

“If you find, say, colon cancer or pancreatic cancer or liver cancer are metastasized, then the deterioration is fairly fast and the outcomes are very poor,” he said. But with previously untreated metastatic prostate cancer, “there are many lines of treatment that can, if not cure it, certainly keep it under control for many years, with good quality of life.”

Sandler, who focuses on radiation oncology, said ADT treatment can cause loss of bone density or muscle mass, so Biden will likely be encouraged to stick to a fitness regimen or take medications to counter those effects.

He may also receive radiation to more heavily target specific pockets of cancer, including where it has metastasized to the bone, but that would depend on the number of metastatic sites, Sandler said — with radiation more likely the fewer sites there are.

“If there’s cancer all over the place, then there’s probably no benefit,” he said.

If you have been to an ER lately — or if you’ve watched the disturbingly accurate TV show “The Pitt” — you’ve seen scenes that resemble field hospitals more than state-of-the-art medical centers. Waiting rooms have been turned into makeshift care zones. Chairs, cots and cubicles serve as gurneys. Providers eyeball the sick and injured and “shotgun” orders for patients. It feels chaotic and unwelcoming because it is.

This is the new normal for emergency departments in the United States, the result of a dramatic rise in the number of ER beds occupied by patients waiting for a space on a traditional hospital ward. We call them “boarders” and in many emergency departments, they routinely account for half or more of all available care space.

With a fraction of beds in play for new arrivals, waiting room patients — even some arriving by ambulance — are increasingly likely to be seen, examined and treated in the lobby. The consequences are as predictable as they are devastating: worse patient outcomes, fragmented care, longer hospital stays, ballooning costs and rising frustration and anger among staff and patients.

Less visible — but no less harmful — is the toll this takes on young doctors in training.

A recent study led by Dr. Katja Goldflam, a Yale professor, documents the scale of the problem. Nearly three-quarters of the emergency medicine residents she surveyed reported that boarding had highly negative effects on their training. They expressed anxiety and a mounting emotional toll over their diminishing ability to manage patients or handle department surges with confidence, and their growing sense that they could not provide the kind of care they’d expect for their own families.

As emergency medicine educators with a combined six decades of experience, this feels personal to us. We are failing our trainees. We are failing our patients. And we are compromising the future of doctors and patients alike.

The damage is not theoretical. One of us recently experienced it personally, when his father — during the final months of his life — visited two prestigious ERs. Both times, recently trained physicians missed straightforward but life-threatening problems after brief, stopgap-style encounters. Poor clinical judgment is more likely, and more consequential, in a hurried and overwhelmed care environment.

Today, medical education is no longer centered on memorizing facts. With smartphones, decision-support tools and now AI, information is everywhere. What sets a good doctor apart is judgment — the ability to navigate uncertainty, synthesize complex data and make decisive, accurate choices. Building this kind of judgment requires many patient encounters — “reps.”

No amount of classroom learning, reading or podcast listening can replace the formative experience of confronting a clinical puzzle in a patient who has entrusted you with their care. Yet in today’s crowded ERs, physicians in training are losing access to these crucial face-to-face encounters and the skills, competence and confidence they teach.

Shift change “rounds” — once a space for discussion and reflection — now operate more like inventory checks: Here’s a 78-year-old with heart failure, there’s a 35-year-old with appendicitis still awaiting an OR.

Meanwhile, as the waiting room overflows, doctors scatter into the lobby to see new arrivals, hoping to reduce the backlog. “Lobby medicine” — a sanitized term for care delivered in a setting stripped of privacy, dignity and safety — is more than a logistical nightmare. It sends a terrible message to young physicians: that cursory patient assessments, firing off broad-spectrum tests and “moving the meat” is acceptable. It is not.

Why is boarding getting worse?

COVID-19 was the inflection point. While volumes dipped early in the pandemic, they rebounded within a year — and in 2024, according to national hospital metrics, stood at 10% above 2021 levels. In 2023, research showed a 60% increase in boarding and fourfold increase in median boarding times compared with pre-pandemic ERs.

The reasons are complex and systemic: financial pressure to keep hospital beds full (every open space is lost revenue), an aging population with greater needs, dwindling access to primary care and a collapsing system of rehab, skilled nursing or home health options. Hospitals are boxed in, forced to provide basic care while waiting days, sometimes weeks, for aftercare services to become available. It is not uncommon for a third or more of the patients in a hospital to be on hold pending an appropriate discharge destination. The bottleneck trickles down: Wards become holding areas, the ER becomes a de facto ward and the lobby becomes the ER.

So, what’s the fix?

The simple answer — just end boarding — has been the rallying cry of well-intentioned efforts for decades. Nearly all have failed. Why? Because emergency department crowding is not the root problem. It’s the canary in the coal mine of a dysfunctional healthcare delivery system riddled with misaligned incentives and priorities.

Real change will require collective outrage that spills beyond the ERs, into the inboxes and onto the agendas of hospital administrators, insurance executives and elected officials.

Consider air travel. Imagine if Los Angeles International Airport shut down three of its four runways, forcing all takeoffs and landings onto one. Travelers would revolt. The Federal Aviation Administration would intervene. The system would be made to fix itself — because it’s unsafe, ineffective and unsustainable.

But when the same thing happens in healthcare, some patients may bark in anger and frustration at the multi-hour waits, but most simply shrug, grateful, finally, for an exhausted ER doc’s time.

Enough.

If we want better healthcare it means investing more — adding beds, staffing and aftercare capacity. It means creating primary care options other than a default trip to the ER. It means reclaiming the ER not just as a place for healing, but as a place for learning. A place where doctors are taught not in disaster zones, but in environments that allow for connection and understanding of our patients and their diseases. Finally, it means recognizing that designing and investing in better systems and in medical education is crucial to public safety.

Training a great doctor is like training a great athlete. You can’t learn to sink a three-pointer by watching YouTube. You have to step onto the court. In medicine, that means standing in front of a patient and deciding: What now?

That experience — raw, real and imperfect — is irreplaceable. And we’re losing it.

How we care for patients today will define how we all will be cared for tomorrow.

Eric Snoey is an attending emergency medicine physician in Oakland. Mark Morocco is a Los Angeles physician and professor of emergency medicine.