-
The first patient to be treated with an antibiotic
-
was a policeman from Oxford.
-
On his day off from work,
-
he was scratched by a rose thorn
while working in the garden.
-
That small scratch became infected.
-
Over the next few days, his head was swollen
-
with abscesses,
-
and in fact his eye was so infected
-
that they had to take it out,
-
and by February of 1941,
-
this poor man was on the verge of dying.
-
He was at Radcliffe Infirmary in Oxford,
-
and fortunately for him,
-
a small team of doctors
-
led by a Dr. Howard Florey
-
had managed to synthesize
-
a very small amount of penicillin,
-
a drug that had been discovered
-
12 years before by Alexander Fleming
-
but had never actually been used to treat a human,
-
and indeed no one even knew if the drug would work,
-
if it was full of impurities that would kill the patient,
-
but Florey and his team figured
-
if they had to use it, they might as well use it
-
on someone who was going to die anyway.
-
So they gave Albert Alexander,
-
this Oxford policeman, the drug,
-
and within 24 hours,
-
he started getting better.
-
His fever went down, his appetite came back.
-
Secondly, he was doing much better.
-
He was starting to run out of penicillin,
-
so what they would do was run with his urine
-
across the road to re-synthesize the penicillin
-
from his urine and give it back to him,
-
and that worked.
-
Day four, well on the way to recovery.
-
This was a miracle.
-
Day five, they ran out of penicillin,
-
and the poor man died.
-
So that story didn't end that well,
-
but fortunately for millions of other people
-
like this child who was treated again
-
in the early 1940s,
-
who was again dying of abscesses,
-
and within just six days, you can see,
-
recovered thanks to this wonder drug penicillin.
-
Millions have lived,
-
and global health has been transformed.
-
Now, antibiotics have been used
-
for patients like this,
-
but they've also been used rather frivolously
-
in some instances
-
for treating someone with just a cold or the flu
-
which they might not have responded to an antibiotic,
-
and they've also been used in large quantities
-
sub-therapeutically, which
means in small concentrations,
-
to make chicken and hogs grow faster.
-
Just to save a few pennies on the price of meat,
-
we've spent a lot of antibiotics on animals,
-
not for treatment, not for sick animals,
-
but primarily for growth promotion.
-
Now, what did that lead us to?
-
Basically, the massive use of antibiotics
-
around the world
-
has imposed such large
selection pressure on bacteria
-
that resistance is now a problem,
-
because we've now selected for just
-
the resistant bacteria.
-
And I'm sure you've all read
about this in the newspapers,
-
you've seen this in every magazine
-
that you come across,
-
but I really want you to appreciate
-
the significance of this problem.
-
This is serious.
-
The next slide I'm about to show you
-
is of carbapenum resistance in acinetobacter.
-
Acinetobacter is a nasty hospital bug,
-
and carbapenum is pretty much
-
the strongest class of antibiotics
-
that we can throw at this bug.
-
And you can see in 1999,
-
this is the pattern of resistance,
-
mostly under about 10 percent
across the United States.
-
Now watch what happens when we play the video.
-
So I don't know where you live,
-
but wherever it is, it certainly is a lot worse now
-
than it was in 1999,
-
and that is the problem of antibiotic resistance.
-
It's a global issue
-
affecting both rich and poor countries,
-
and at the heart of it, you might say, well,
-
isn't this really just a medical issue?
-
If we taught doctors of how
not to use antibiotics as much,
-
if we taught patients how not to demand antibiotics,
-
perhaps this really wouldn't be an issue,
-
and maybe the pharmaceutical companies
-
should be working harder to develop
-
more antibiotics.
-
Now, it turns out that there's something
-
fundamental about antibiotics
-
which make it different from other drugs,
-
which is that if I misuse antibiotics
-
or I use antibiotics,
-
not only am I affected but others are affected as well,
-
in the same as if I choose to drive to work
-
or take a plane to go somewhere,
-
that the costs I impose on others
-
through global climate change go everywhere,
-
and I don't necessarily take
these costs into consideration.
-
This is what economists might call
-
a problem of the commons,
-
and the problem of the commons is exactly
-
what we face in the case of antibiotics as well;
-
that we don't consider,
-
and we, including individuals, patients,
-
hospitals, entire health systems,
-
do not consider the costs that they impose on others
-
by the way antibiotics are actually used.
-
Now, that's a problem that's similar
-
to another area that we all know about,
-
which is of fuel use, and energy,
-
and of course energy use
-
both depletes energy as well as
-
leads to local pollution and climate change.
-
And typically, in the case of energy,
-
there are two ways in which
you can deal with the problem.
-
One is, we can make better
use of the oil that we have,
-
and that's analogous to making better use
-
of existing antibiotics,
-
and we can do this in a number of ways
-
that we'll talk about in a second,
-
but the other option is the "drill, baby, drill" option,
-
which in the case of antibiotics
-
is to go find new antibiotics.
-
Now, these are not separate.
-
They're related, because if we invest heavily
-
in new oil wells,
-
we reduce the incentives for conservation of oil
-
in the same way that's going to happen for antibiotics.
-
The reverse is also going to happen, which is that
-
if we use our antibiotics appropriately,
-
we don't necessarily have to make the investments
-
in new drug development.
-
And if you thought that these two were entirely,
-
fully balanced between these two options,
-
you might consider the fact that
-
this is really a game that we're playing.
-
The game is really one of coevolution,
-
and coevolution is, in this particular picture,
-
between cheetahs and gazelles.
-
Cheetahs have evolved to run faster,
-
because if they didn't run faster,
-
they wouldn't get any lunch.
-
Gazelles have evolved to run faster because
-
if they don't run faster, they would be lunch.
-
Now, this is the game we're
playing against the bacteria,
-
except we're not the cheetahs,
-
we're the gazelles,
-
and the bacteria would,
-
just in the course of this little talk,
-
would have had kids and grandkids
-
and figured out how to be resistant
-
just by selection and trial and error,
-
trying it over and over again.
-
Whereas how do we stay ahead of the bacteria?
-
We have drug discovery processes,
-
screening molecules,
-
we have clinical trials,
-
and then, when we think we have a drug,
-
then we have the FDA regulatory process.
-
And once we go through all of that,
-
then we try to stay one step ahead
-
of the bacteria.
-
Now, this is clearly not a game that can be sustained,
-
or one that we can win
-
by simply innovating to stay ahead.
-
We've got to slow the pace of coevolution down,
-
and there are ideas that we can borrow from energy
-
that are helpful in thinking about
-
how we might want to do this in the case
-
of antibiotics as well.
-
Now, if you think about how we deal with
-
energy pricing, for instance,
-
we consider emissions taxes,
-
which means we're imposing the costs of pollution
-
on people who actually use that energy.
-
We might consider doing that for antibiotics as well,
-
and perhaps that would make sure that antibiotics
-
actually get used appropriately.
-
There are clean energy subsidies,
-
which are to switch to fuels
which don't pollute as much
-
or perhaps don't need fossil fuels.
-
Now, the analogy here is perhaps we need
-
to move away from using antibiotics,
-
and if you think about it,
-
what are good substitutes for antibiotics?
-
Well, turns out that anything that reduces
-
the need for the antibiotic would really work,
-
so that could include improving
hospital infection control
-
or vaccinating people,
-
particularly against the seasonal influenza,
-
and the seasonal flu is probably
-
the biggest driver of antibiotic use,
-
both in this country as well
as in many other countries,
-
and that would really help.
-
A third option might include
something like tradeable permits,
-
which are, we actually,
-
and these seem like faraway scenarios,
-
but if you consider the fact that we might not
-
have antibiotics for many people who have infections,
-
we might consider the fact that we might
-
want to allocate who actually gets to use
-
some of these antibiotics over others,
-
and some of these might have to
be on the basis of clinical need,
-
but also on the basis of pricing.
-
And certainly consumer education works.
-
Very often, people overuse antibiotics
-
or prescribe too much without necessarily
-
knowing that they do so,
-
and feedback mechanisms
-
have been found to be useful,
-
both on energy —
-
When you tell someone that they're using
-
a lot of energy during peak hour,
-
they tend to cut back,
-
and the same sort of example has been performed
-
even in the case of antibiotics.
-
A hospital in St. Louis basically would put up
-
on a chart the names of surgeons
-
in the ordering of how much antibiotics they'd used
-
in the previous month,
-
and this was purely an informational feedback,
-
there was no shaming,
-
but essentially that provided some information back
-
to surgeons that maybe they could rethink
-
how they were using antibiotics.
-
Now, there's a lot that can be done
-
on the supply side as well.
-
If you look at the price of penicillin,
-
the cost per day is about 10 cents.
-
It's a fairly cheap drug.
-
If you take drugs that have
been introduced since then
-
— linezolid or daptomycin —
-
those are significantly more expensive,
-
so to a world that has been used
-
to paying 10 cents a day for antibiotics,
-
the idea of paying 180 dollars per day
-
seems like a lot.
-
But what is that really telling us?
-
That price is telling us
-
that we should no longer
-
take cheap, effective antibiotics as a given
-
into the foreseeable future,
-
and that price is a signal to us
-
that perhaps we need to be paying
-
much more attention to conservation.
-
That price is also a signal
-
that maybe we need to start
looking at other technologies,
-
in the same way that gasoline prices are a signal
-
and an impetus, to, say,
-
the development of electric cars.
-
Prices are important signals
-
that we need to pay attention to,
-
but we also need to consider the fact that
-
although these high prices
seem unusual for antibiotics,
-
they're nothing compared to the price per day
-
of some cancer drugs,
-
which might save a patient's life only
for a few months or perhaps a year,
-
whereas antibiotics would potentially
-
save a patient's life forever.
-
So this is going to involve
-
a whole new paradigm shift,
-
and it's also a scary shift because
-
in many parts of this country,
-
in many parts of the world,
-
the idea of paying 200 dollars
-
for a day of antibiotic treatment
-
is simply unimaginable.
-
So we need to think about that.
-
Now, there are backstop options,
-
which is other alternative technologies
-
that people are working on.
-
It includes bacteriophages, probiotics,
-
quorum sensing, synbiotics.
-
Now, all of these are useful avenues to pursue,
-
and they will become even more lucrative
-
when the price of new antibiotics starts going higher,
-
and we've seen that the
market does actually respond,
-
and the government is now considering
-
ways of subsidizing new antibiotics and development.
-
But there are challenges here.
-
We don't want to just throw money at a problem.
-
What we want to be able to do
-
is invest in new antibiotics
-
in ways that actually encourage
-
appropriate use and sales of those antibiotics,
-
and that really is the challenge here.
-
Now, going back to these technologies,
-
you all remember the line from that famous
-
dinosaur film, "Nature will find a way."
-
So it's not as if these are permanent solutions.
-
We really have to remember that,
-
whatever the technology might be,
-
that nature will find some way to work around it.
-
You might, well, this is just a problem
-
just with antibiotics and with bacteria,
-
but it turns out that we have the exact same
-
identical problem in many other fields as well,
-
with multi-drug resistant tuberculosis,
-
which is a serious problem in India and South Africa.
-
Thousands of patients are dying because
-
the second line drugs are so expensive,
-
and in some instances, even those don't work
-
and you have XDR TB.
-
Viruses are become resistant.
-
Agricultural pests. Malaria parasites.
-
Right now, much of the world depends on
-
one drug, artemisinin drugs,
-
essentially to treat malaria.
-
Resistance to artemisinin has already emerged,
-
and if this were to become widespread,
-
that puts at risk
-
the single drug that we have to treat malaria
-
around the world
-
in a way that's currently safe an efficacious.
-
Mosquitoes develop resistance.
-
If you have kids, you probably know about head lice,
-
and if you're from New York City, I understand that
-
the specialty there is bedbugs.
-
So those are also resistant.
-
And we have to bring an
example from across the pond.
-
Turns out that rats are also resistant to poisons.
-
Now, what's common to all of these things is
-
the idea that we've had these technologies
-
to control nature only for the last 70, 80,
-
or a hundred years,
-
and essentially in a blink,
-
we have squandered our ability to control,
-
because we have not recognized
-
that natural selection and evolution was going to find
-
a way to get back,
-
and we need to completely rethink
-
how we're going to use
-
measures to control biological organisms,
-
and rethink how we incentivize
-
the development, introduction,
-
in the case of antibiotics prescription,
-
and use of these valuable resources.
-
And we really now need to start thinking about them
-
as natural resources.
-
And so that's, we stand at a crossroads.
-
An option is to go through that rethinking
-
and carefully consider incentives
-
to change how we do business.
-
The alternative is
-
a world in which even a blade of grass
-
is a potentially lethal weapon.
-
Thank you.
-
(Applause)