Placeholder Image

Subtitles section Play video

  • The first patient to ever be treated with an antibiotic

  • was a policeman in 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.

  • Second day, he was doing much better.

  • They were 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 a sepsis,

  • 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 carbapenem resistance in acinetobacter.

  • Acinetobacter is a nasty hospital bug,

  • and carbapenem 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 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 makes 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 way 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 could really help.

  • A third option might include something like tradeable permits.

  • 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,