Ramanan Laxminarayan: The coming crisis in antibiotics

105,385 views ・ 2014-11-10

TED


Please double-click on the English subtitles below to play the video.

00:12
The first patient to ever be treated with an antibiotic
0
12602
3558
00:16
was a policeman in Oxford.
1
16160
1533
00:17
On his day off from work,
2
17693
2107
00:19
he was scratched by a rose thorn while working in the garden.
3
19800
3373
00:23
That small scratch became infected.
4
23173
3675
00:26
Over the next few days, his head was swollen
5
26848
2315
00:29
with abscesses,
6
29163
1721
00:30
and in fact his eye was so infected
7
30884
2283
00:33
that they had to take it out,
8
33167
1903
00:35
and by February of 1941,
9
35070
2980
00:38
this poor man was on the verge of dying.
10
38050
2437
00:40
He was at Radcliffe Infirmary in Oxford,
11
40487
3198
00:43
and fortunately for him,
12
43685
2306
00:45
a small team of doctors
13
45991
1050
00:47
led by a Dr. Howard Florey
14
47041
1889
00:48
had managed to synthesize
15
48930
2067
00:50
a very small amount of penicillin,
16
50997
2823
00:53
a drug that had been discovered
17
53820
2081
00:55
12 years before by Alexander Fleming
18
55901
2322
00:58
but had never actually been used to treat a human,
19
58223
3707
01:01
and indeed no one even knew if the drug would work,
20
61930
2410
01:04
if it was full of impurities that would kill the patient,
21
64340
3640
01:07
but Florey and his team figured
22
67980
1914
01:09
if they had to use it, they might as well use it
23
69894
1722
01:11
on someone who was going to die anyway.
24
71616
2565
01:14
So they gave Albert Alexander,
25
74181
3655
01:17
this Oxford policeman, the drug,
26
77836
2879
01:20
and within 24 hours,
27
80715
2417
01:23
he started getting better.
28
83132
2262
01:25
His fever went down, his appetite came back.
29
85394
3976
01:29
Second day, he was doing much better.
30
89370
2313
01:31
They were starting to run out of penicillin,
31
91683
2238
01:33
so what they would do was run with his urine
32
93921
2062
01:35
across the road to re-synthesize the penicillin from his urine
33
95983
2850
01:38
and give it back to him,
34
98833
1935
01:40
and that worked.
35
100768
1248
01:42
Day four, well on the way to recovery.
36
102016
2480
01:44
This was a miracle.
37
104496
1638
01:46
Day five, they ran out of penicillin,
38
106134
4236
01:50
and the poor man died.
39
110370
2267
01:52
So that story didn't end that well,
40
112637
2713
01:55
but fortunately for millions of other people,
41
115350
4350
01:59
like this child who was treated again in the early 1940s,
42
119700
3006
02:02
who was again dying of a sepsis,
43
122706
3034
02:05
and within just six days, you can see,
44
125740
3150
02:08
recovered thanks to this wonder drug, penicillin.
45
128890
3353
02:12
Millions have lived,
46
132243
1958
02:14
and global health has been transformed.
47
134201
3584
02:17
Now, antibiotics have been used
48
137785
2793
02:20
for patients like this,
49
140578
3127
02:23
but they've also been used rather frivolously
50
143705
2137
02:25
in some instances,
51
145842
1744
02:27
for treating someone with just a cold or the flu,
52
147586
2363
02:29
which they might not have responded to an antibiotic,
53
149949
2474
02:32
and they've also been used in large quantities
54
152423
3738
02:36
sub-therapeutically, which means in small concentrations,
55
156161
3642
02:39
to make chicken and hogs grow faster.
56
159803
3183
02:42
Just to save a few pennies on the price of meat,
57
162986
3566
02:46
we've spent a lot of antibiotics on animals,
58
166552
2700
02:49
not for treatment, not for sick animals,
59
169252
2362
02:51
but primarily for growth promotion.
60
171614
3116
02:54
Now, what did that lead us to?
61
174730
2857
02:57
Basically, the massive use of antibiotics
62
177587
2711
03:00
around the world
63
180298
1485
03:01
has imposed such large selection pressure on bacteria
64
181783
3804
03:05
that resistance is now a problem,
65
185587
2653
03:08
because we've now selected for just
66
188240
1770
03:10
the resistant bacteria.
67
190010
1975
03:11
And I'm sure you've all read about this in the newspapers,
68
191985
2840
03:14
you've seen this in every magazine
69
194825
1804
03:16
that you come across,
70
196629
1899
03:18
but I really want you to appreciate
71
198528
1800
03:20
the significance of this problem.
72
200328
2171
03:22
This is serious.
73
202499
1451
03:23
The next slide I'm about to show you is of carbapenem resistance in acinetobacter.
74
203950
4816
03:28
Acinetobacter is a nasty hospital bug,
75
208766
2388
03:31
and carbapenem is pretty much
76
211154
1333
03:32
the strongest class of antibiotics
77
212487
1778
03:34
that we can throw at this bug.
78
214265
2456
03:36
And you can see in 1999
79
216721
3269
03:39
this is the pattern of resistance,
80
219990
2195
03:42
mostly under about 10 percent across the United States.
81
222185
3033
03:45
Now watch what happens when we play the video.
82
225218
3997
03:58
So I don't know where you live,
83
238461
2055
04:00
but wherever it is, it certainly is a lot worse now
84
240516
2902
04:03
than it was in 1999,
85
243418
2497
04:05
and that is the problem of antibiotic resistance.
86
245915
3971
04:09
It's a global issue
87
249886
1687
04:11
affecting both rich and poor countries,
88
251573
2428
04:14
and at the heart of it, you might say, well,
89
254001
2241
04:16
isn't this really just a medical issue?
90
256242
1928
04:18
If we taught doctors how not to use antibiotics as much,
91
258170
2561
04:20
if we taught patients how not to demand antibiotics,
92
260731
2945
04:23
perhaps this really wouldn't be an issue,
93
263676
1455
04:25
and maybe the pharmaceutical companies
94
265131
1989
04:27
should be working harder to develop
95
267120
1755
04:28
more antibiotics.
96
268875
1636
04:30
Now, it turns out that there's something fundamental about antibiotics
97
270511
3379
04:33
which makes it different from other drugs,
98
273890
1783
04:35
which is that if I misuse antibiotics
99
275673
2021
04:37
or I use antibiotics,
100
277694
1737
04:39
not only am I affected but others are affected as well,
101
279431
3860
04:43
in the same way as if I choose to drive to work
102
283291
2338
04:45
or take a plane to go somewhere,
103
285629
2639
04:48
that the costs I impose on others
104
288268
1974
04:50
through global climate change go everywhere,
105
290242
2440
04:52
and I don't necessarily take these costs into consideration.
106
292682
2773
04:55
This is what economists might call a problem of the commons,
107
295455
2879
04:58
and the problem of the commons is exactly
108
298334
1980
05:00
what we face in the case of antibiotics as well:
109
300314
2425
05:02
that we don't consider —
110
302739
2150
05:04
and we, including individuals, patients,
111
304889
3002
05:07
hospitals, entire health systems —
112
307891
3159
05:11
do not consider the costs that they impose on others
113
311050
2148
05:13
by the way antibiotics are actually used.
114
313198
2356
05:15
Now, that's a problem that's similar
115
315554
2405
05:17
to another area that we all know about,
116
317959
1982
05:19
which is of fuel use and energy,
117
319941
1929
05:21
and of course energy use
118
321870
1499
05:23
both depletes energy as well as
119
323369
3082
05:26
leads to local pollution and climate change.
120
326451
3262
05:29
And typically, in the case of energy,
121
329713
1810
05:31
there are two ways in which you can deal with the problem.
122
331523
2308
05:33
One is, we can make better use of the oil that we have,
123
333831
3745
05:37
and that's analogous to making better use
124
337576
2115
05:39
of existing antibiotics,
125
339691
1548
05:41
and we can do this in a number of ways
126
341239
1691
05:42
that we'll talk about in a second,
127
342930
2230
05:45
but the other option is the "drill, baby, drill" option,
128
345160
3687
05:48
which in the case of antibiotics is to go find new antibiotics.
129
348847
4191
05:53
Now, these are not separate.
130
353050
2050
05:55
They're related, because if we invest heavily
131
355100
3422
05:58
in new oil wells,
132
358522
2284
06:00
we reduce the incentives for conservation of oil
133
360806
2954
06:03
in the same way that's going to happen for antibiotics.
134
363760
2526
06:06
The reverse is also going to happen, which is that
135
366286
2168
06:08
if we use our antibiotics appropriately,
136
368454
2338
06:10
we don't necessarily have to make the investments
137
370792
2781
06:13
in new drug development.
138
373573
2177
06:15
And if you thought that these two were entirely,
139
375750
2716
06:18
fully balanced between these two options,
140
378466
1822
06:20
you might consider the fact that
141
380288
2183
06:22
this is really a game that we're playing.
142
382471
2272
06:24
The game is really one of coevolution,
143
384743
2441
06:27
and coevolution is, in this particular picture,
144
387184
2932
06:30
between cheetahs and gazelles.
145
390116
2356
06:32
Cheetahs have evolved to run faster,
146
392472
1618
06:34
because if they didn't run faster,
147
394090
1577
06:35
they wouldn't get any lunch.
148
395667
1946
06:37
Gazelles have evolved to run faster because
149
397613
2687
06:40
if they don't run faster, they would be lunch.
150
400300
3209
06:43
Now, this is the game we're playing against the bacteria,
151
403509
2886
06:46
except we're not the cheetahs,
152
406395
2057
06:48
we're the gazelles,
153
408452
1477
06:49
and the bacteria would,
154
409929
2787
06:52
just in the course of this little talk,
155
412716
1833
06:54
would have had kids and grandkids
156
414549
1426
06:55
and figured out how to be resistant
157
415975
2385
06:58
just by selection and trial and error,
158
418360
2474
07:00
trying it over and over again.
159
420834
1912
07:02
Whereas how do we stay ahead of the bacteria?
160
422746
3772
07:06
We have drug discovery processes,
161
426518
2054
07:08
screening molecules,
162
428572
1630
07:10
we have clinical trials,
163
430202
1728
07:11
and then, when we think we have a drug,
164
431930
2148
07:14
then we have the FDA regulatory process.
165
434078
3745
07:17
And once we go through all of that,
166
437823
2178
07:20
then we try to stay one step ahead
167
440001
2265
07:22
of the bacteria.
168
442266
2296
07:24
Now, this is clearly not a game that can be sustained,
169
444562
2777
07:27
or one that we can win
170
447339
1137
07:28
by simply innovating to stay ahead.
171
448476
1837
07:30
We've got to slow the pace of coevolution down,
172
450313
3305
07:33
and there are ideas that we can borrow from energy
173
453618
3682
07:37
that are helpful in thinking about
174
457300
1770
07:39
how we might want to do this in the case
175
459070
1537
07:40
of antibiotics as well.
176
460607
1546
07:42
Now, if you think about how we deal with
177
462153
2240
07:44
energy pricing, for instance,
178
464393
1423
07:45
we consider emissions taxes,
179
465816
1849
07:47
which means we're imposing the costs of pollution
180
467665
2584
07:50
on people who actually use that energy.
181
470249
2831
07:53
We might consider doing that for antibiotics as well,
182
473080
2980
07:56
and perhaps that would make sure that antibiotics
183
476060
2711
07:58
actually get used appropriately.
184
478771
2401
08:01
There are clean energy subsidies,
185
481172
2028
08:03
which are to switch to fuels which don't pollute as much
186
483200
3055
08:06
or perhaps don't need fossil fuels.
187
486255
2845
08:09
Now, the analogy here is, perhaps we need
188
489100
2860
08:11
to move away from using antibiotics,
189
491960
2260
08:14
and if you think about it, what are good substitutes for antibiotics?
190
494220
3716
08:17
Well, turns out that anything that reduces
191
497936
2164
08:20
the need for the antibiotic would really work,
192
500100
2243
08:22
so that could include improving hospital infection control
193
502343
3142
08:25
or vaccinating people,
194
505485
2895
08:28
particularly against the seasonal influenza.
195
508380
2297
08:30
And the seasonal flu is probably
196
510677
2531
08:33
the biggest driver of antibiotic use,
197
513208
3004
08:36
both in this country as well as in many other countries,
198
516212
2919
08:39
and that could really help.
199
519131
2020
08:41
A third option might include something like tradeable permits.
200
521151
4103
08:45
And these seem like faraway scenarios,
201
525254
4246
08:49
but if you consider the fact that we might not
202
529500
2427
08:51
have antibiotics for many people who have infections,
203
531927
3383
08:55
we might consider the fact that we might
204
535310
2237
08:57
want to allocate who actually gets to use
205
537547
2311
08:59
some of these antibiotics over others,
206
539858
2714
09:02
and some of these might have to be on the basis of clinical need,
207
542572
3326
09:05
but also on the basis of pricing.
208
545898
1935
09:07
And certainly consumer education works.
209
547833
1910
09:09
Very often, people overuse antibiotics
210
549743
2601
09:12
or prescribe too much without necessarily
211
552344
2277
09:14
knowing that they do so,
212
554621
1606
09:16
and feedback mechanisms
213
556227
1431
09:17
have been found to be useful,
214
557658
1902
09:19
both on energy —
215
559560
1929
09:21
When you tell someone that they're using
216
561489
1540
09:23
a lot of energy during peak hour,
217
563029
1917
09:24
they tend to cut back,
218
564946
1470
09:26
and the same sort of example has been performed
219
566416
1767
09:28
even in the case of antibiotics.
220
568183
1810
09:29
A hospital in St. Louis basically would put up
221
569993
1981
09:31
on a chart the names of surgeons
222
571974
4192
09:36
in the ordering of how much antibiotics they'd used
223
576166
2219
09:38
in the previous month,
224
578385
1944
09:40
and this was purely an informational feedback,
225
580329
2342
09:42
there was no shaming,
226
582671
1183
09:43
but essentially that provided some information back
227
583854
2135
09:45
to surgeons that maybe they could rethink
228
585989
1954
09:47
how they were using antibiotics.
229
587943
2229
09:50
Now, there's a lot that can be done
230
590172
2014
09:52
on the supply side as well.
231
592186
2149
09:54
If you look at the price of penicillin,
232
594335
1777
09:56
the cost per day is about 10 cents.
233
596112
1651
09:57
It's a fairly cheap drug.
234
597763
1758
09:59
If you take drugs that have been introduced since then —
235
599521
2137
10:01
linezolid or daptomycin —
236
601658
2644
10:04
those are significantly more expensive,
237
604302
1878
10:06
so to a world that has been used to paying 10 cents a day for antibiotics,
238
606180
5451
10:11
the idea of paying 180 dollars per day
239
611633
2530
10:14
seems like a lot.
240
614163
1567
10:15
But what is that really telling us?
241
615730
1987
10:17
That price is telling us
242
617717
1965
10:19
that we should no longer
243
619682
1898
10:21
take cheap, effective antibiotics as a given
244
621580
4117
10:25
into the foreseeable future,
245
625697
1767
10:27
and that price is a signal to us
246
627464
2530
10:29
that perhaps we need to be paying
247
629994
1609
10:31
much more attention to conservation.
248
631603
2553
10:34
That price is also a signal
249
634156
2704
10:36
that maybe we need to start looking at other technologies,
250
636860
2875
10:39
in the same way that gasoline prices are a signal
251
639735
2652
10:42
and an impetus, to, say,
252
642387
2590
10:44
the development of electric cars.
253
644977
1868
10:46
Prices are important signals
254
646845
1777
10:48
and we need to pay attention,
255
648622
1586
10:50
but we also need to consider the fact that
256
650208
2452
10:52
although these high prices seem unusual for antibiotics,
257
652660
4252
10:56
they're nothing compared to the price per day
258
656912
2239
10:59
of some cancer drugs,
259
659151
1384
11:00
which might save a patient's life only for a few months or perhaps a year,
260
660535
3370
11:03
whereas antibiotics would potentially
261
663905
1770
11:05
save a patient's life forever.
262
665675
1826
11:07
So this is going to involve
263
667501
1319
11:08
a whole new paradigm shift,
264
668820
1962
11:10
and it's also a scary shift because
265
670782
1856
11:12
in many parts of this country,
266
672638
2329
11:14
in many parts of the world,
267
674967
1744
11:16
the idea of paying 200 dollars
268
676711
2069
11:18
for a day of antibiotic treatment
269
678780
2891
11:21
is simply unimaginable.
270
681671
2542
11:24
So we need to think about that.
271
684213
1734
11:25
Now, there are backstop options,
272
685947
1813
11:27
which is other alternative technologies
273
687760
2676
11:30
that people are working on.
274
690436
1194
11:31
It includes bacteriophages, probiotics,
275
691630
2652
11:34
quorum sensing, synbiotics.
276
694282
4048
11:38
Now, all of these are useful avenues to pursue,
277
698330
3039
11:41
and they will become even more lucrative
278
701369
2610
11:43
when the price of new antibiotics starts going higher,
279
703979
3081
11:47
and we've seen that the market does actually respond,
280
707060
2897
11:49
and the government is now considering
281
709957
2008
11:51
ways of subsidizing new antibiotics and development.
282
711965
3767
11:55
But there are challenges here.
283
715732
1723
11:57
We don't want to just throw money at a problem.
284
717455
1575
11:59
What we want to be able to do
285
719030
1519
12:00
is invest in new antibiotics
286
720549
2279
12:02
in ways that actually encourage
287
722828
2976
12:05
appropriate use and sales of those antibiotics,
288
725804
3020
12:08
and that really is the challenge here.
289
728824
2463
12:11
Now, going back to these technologies,
290
731287
2329
12:13
you all remember the line from that famous
291
733616
2363
12:15
dinosaur film, "Nature will find a way."
292
735979
2226
12:18
So it's not as if these are permanent solutions.
293
738205
3319
12:21
We really have to remember that, whatever the technology might be,
294
741524
4086
12:25
that nature will find some way to work around it.
295
745610
2876
12:28
You might think, well, this is just a problem
296
748486
2071
12:30
just with antibiotics and with bacteria,
297
750557
2744
12:33
but it turns out that we have the exact same
298
753301
1946
12:35
identical problem in many other fields as well,
299
755247
2734
12:37
with multidrug-resistant tuberculosis,
300
757981
2952
12:40
which is a serious problem in India and South Africa.
301
760933
3562
12:44
Thousands of patients are dying because
302
764495
1787
12:46
the second-line drugs are so expensive,
303
766282
1834
12:48
and in some instances, even those don't work
304
768116
2227
12:50
and you have XDR TB.
305
770343
2070
12:52
Viruses are becoming resistant.
306
772413
1811
12:54
Agricultural pests. Malaria parasites.
307
774224
3166
12:57
Right now, much of the world depends on
308
777390
1783
12:59
one drug, artemisinin drugs,
309
779173
3697
13:02
essentially to treat malaria.
310
782870
1956
13:04
Resistance to artemisinin has already emerged,
311
784826
2587
13:07
and if this were to become widespread,
312
787413
2354
13:09
that puts at risk
313
789767
1348
13:11
the single drug that we have to treat malaria around the world
314
791115
2891
13:14
in a way that's currently safe and efficacious.
315
794006
3214
13:17
Mosquitos develop resistance.
316
797220
1798
13:19
If you have kids, you probably know about head lice,
317
799018
2237
13:21
and if you're from New York City,
318
801255
1713
13:22
I understand that the specialty there is bedbugs.
319
802968
2733
13:25
So those are also resistant.
320
805701
2255
13:27
And we have to bring an example from across the pond.
321
807956
2879
13:30
Turns out that rats are also resistant to poisons.
322
810835
2355
13:33
Now, what's common to all of these things is
323
813190
2701
13:35
the idea that we've had these technologies
324
815891
2706
13:38
to control nature only for the last 70, 80 or 100 years
325
818597
4621
13:43
and essentially in a blink,
326
823218
3028
13:46
we have squandered our ability to control,
327
826246
2551
13:48
because we have not recognized
328
828797
2491
13:51
that natural selection and evolution was going to find
329
831288
2812
13:54
a way to get back,
330
834100
1174
13:55
and we need to completely rethink
331
835274
2049
13:57
how we're going to use
332
837323
2343
13:59
measures to control biological organisms,
333
839666
3094
14:02
and rethink how we incentivize
334
842760
3464
14:06
the development, introduction,
335
846224
2226
14:08
in the case of antibiotics prescription,
336
848450
2668
14:11
and use of these valuable resources.
337
851118
3772
14:14
And we really now need to start thinking about them
338
854890
2380
14:17
as natural resources.
339
857270
1958
14:19
And so we stand at a crossroads.
340
859228
2238
14:21
An option is to go through that rethinking
341
861466
3159
14:24
and carefully consider incentives
342
864625
1813
14:26
to change how we do business.
343
866438
2554
14:28
The alternative is
344
868992
2261
14:31
a world in which even a blade of grass
345
871253
3083
14:34
is a potentially lethal weapon.
346
874336
2429
14:36
Thank you.
347
876765
1800
14:38
(Applause)
348
878565
2735
About this website

This site will introduce you to YouTube videos that are useful for learning English. You will see English lessons taught by top-notch teachers from around the world. Double-click on the English subtitles displayed on each video page to play the video from there. The subtitles scroll in sync with the video playback. If you have any comments or requests, please contact us using this contact form.

https://forms.gle/WvT1wiN1qDtmnspy7