Ramanan Laxminarayan: The coming crisis in antibiotics

Translator: Aitor Valle Reviewer: Serv. de Norm. Lingüística U. de Santiago de Compostela

The first patient to ever be treated with an antibiotic

(Aplausos)

O primeiro paciente que foi tratado con antibióticos

was a policeman in Oxford.

foi un policía de Oxford.

On his day off from work,

No seu tempo de lecer,

he was scratched by a rose thorn while working in the garden.

namentres traballaba no seu xardín rabuñouse coa espiña dunha rosa

That small scratch became infected.

e esa pequena ferida infectouse.

Over the next few days, his head was swollen

Nos seguintes días a súa cabeza foise inflamando,

a causa da aparición de abscesos,

with abscesses,

and in fact his eye was so infected

e de feito, tiña un ollo tan infectado que llo tiveron que sacar.

that they had to take it out,

and by February of 1941,

En febreiro de 1941,

this poor man was on the verge of dying.

o pobre home estaba a piques de morrer.

He was at Radcliffe Infirmary in Oxford,

Estaba ingresado no Radcliffe Infirmary de Oxford

and fortunately for him,

e por sorte para el,

a small team of doctors

había un pequeno equipo médico

led by a Dr. Howard Florey

baixo a dirección do Dr. Howard Florey

had managed to synthesize

que conseguira sintetizar

a very small amount of penicillin,

un chisco de penicilina,

a drug that had been discovered

un fármaco que fora descuberto 12 anos antes por Alexander Fleming,

12 years before by Alexander Fleming

but had never actually been used to treat a human,

pero que xamais se usara para tratar doenzas humanas

and indeed no one even knew if the drug would work,

e que ninguén sabía se ía funcionar

if it was full of impurities that would kill the patient,

ou se as impurezas que contiña matarían o paciente.

but Florey and his team figured

Aínda así, Florey e o seu equipo decidiron usalo,

if they had to use it, they might as well use it

xa que postos a facelo, mellor con alguén que fose morrer de tódalas maneiras.

on someone who was going to die anyway.

Polo tanto, déronlle a menciña a Albert Alexander,

So they gave Albert Alexander,

this Oxford policeman, the drug,

o policía de Oxford,

and within 24 hours,

e nas primeiras 24 horas,

he started getting better.

comezou a mellorar.

His fever went down, his appetite came back.

Baixoulle a febre e recuperou o apetito.

Second day, he was doing much better.

No segundo día, a súa mellora foi considerable,

They were starting to run out of penicillin,

pero comezaban a quedar sen penicilina

so what they would do was run with his urine

polo que utilizaron os ouriños deste

across the road to re-synthesize the penicillin from his urine

co fin de resintetizar máis penicilina

and give it back to him,

e administrarlla de novo,

and that worked.

o cal funcionou.

Day four, well on the way to recovery.

No cuarto día a recuperación ía por bo camiño.

This was a miracle.

Semellaba un milagre,

Day five, they ran out of penicillin,

mais no quinto día, esgotouse a penicilina

and the poor man died.

e o coitado morreu.

So that story didn't end that well,

Esta historia non rematou ben,

but fortunately for millions of other people,

pero, por sorte para millóns de persoas,

like this child who was treated again in the early 1940s,

coma esta nena que foi tratada a comezos de 1940,

who was again dying of a sepsis,

quen tamén estaba a morrer por unha septicemia,

and within just six days, you can see,

e tan só en seis días, como podedes ver,

recovered thanks to this wonder drug, penicillin.

recuperouse grazas ao marabilloso fármaco da penicilina.

Millions have lived,

Millóns de persoas sobreviviron

and global health has been transformed.

e mudou a saúde global.

Now, antibiotics have been used

Os antibióticos téñense empregado

for patients like this,

en pacientes coma este

but they've also been used rather frivolously

aínda que tamén se empregaron á lixeira nalgunhas circunstancias,

in some instances,

for treating someone with just a cold or the flu,

para tratar un simple constipado ou gripe,

which they might not have responded to an antibiotic,

enfermidades elas

con moi baixa resposta

aos antibióticos.

and they've also been used in large quantities

Tamén se teñen empregado

de forma masiva, subterapeuticamente,

sub-therapeutically, which means in small concentrations,

é dicir, en baixas concentracións,

to make chicken and hogs grow faster.

co obxectivo de que galiñas e porcos engorden moi rápido.

Just to save a few pennies on the price of meat,

Tan só para aforrar algún céntimo no prezo da carne,

we've spent a lot of antibiotics on animals,

gastamos moitísimo en antibióticos para animais,

not for treatment, not for sick animals,

non para tratar os que están enfermos,

but primarily for growth promotion.

senón, principalmente, para potenciar o seu crecemento.

Now, what did that lead us to?

Co cal, a que nos levou isto?

Basically, the massive use of antibiotics

Basicamente, o uso masivo de antibióticos

around the world

por todo o mundo

has imposed such large selection pressure on bacteria

trouxo o problema da resistencia das bacterias

that resistance is now a problem,

debido ao feito da selección das máis fortes,

because we've now selected for just

grazas a que nós mesmos fixemos posible a selección.

the resistant bacteria.

And I'm sure you've all read about this in the newspapers,

Teño a certeza de que todos leron nos xornais sobre o tema,

you've seen this in every magazine

que o viron nas revistas que tiñan á man,

that you come across,

but I really want you to appreciate

pero realmente quero que se dean conta

the significance of this problem.

da importancia deste problema.

This is serious.

Isto é serio.

The next slide I'm about to show you is of carbapenem resistance in acinetobacter.

A seguinte diapositiva que lles vou amosar

é unha mostra da resistencia do Acinetobacter ao carbapenem.

Acinetobacter is a nasty hospital bug,

O Acinetobacter é un perigoso xerme hospitalario

and carbapenem is pretty much

e o carbapenem é un dos tipos de antibióticos máis poderosos

the strongest class of antibiotics

that we can throw at this bug.

que se pode administrar contra ese xerme.

And you can see in 1999

Poden ver que en 1999

this is the pattern of resistance,

a mostra de datos sobre a resistencia,

mostly under about 10 percent across the United States.

situábase na súa meirande parte por debaixo do 10 % en todo EE. UU.

Now watch what happens when we play the video.

Agora vexan o que acontece ao avanzar o vídeo.

So I don't know where you live,

Non sei onde viven vostedes

but wherever it is, it certainly is a lot worse now

pero sexa onde sexa, seguramente a situación

than it was in 1999,

é peor agora que no 1999,

and that is the problem of antibiotic resistance.

ese é o problema da resistencia aos antibióticos.

It's a global issue

É un problema mundial

affecting both rich and poor countries,

que afecta aos países pobres e aos ricos por igual

and at the heart of it, you might say, well,

aínda que no fondo, poderiades pensar

isn't this really just a medical issue?

non pasa nada, só é un problema médico!

If we taught doctors how not to use antibiotics as much,

Se lles ensinásemos aos médicos a non dar tantos antibióticos

if we taught patients how not to demand antibiotics,

e aos pacientes a non pedilos,

perhaps this really wouldn't be an issue,

ao mellor non sería un problema

and maybe the pharmaceutical companies

e se cadra as compañías farmacéuticas

should be working harder to develop

farían o esforzo de desenvolver

more antibiotics.

novos antibióticos.

Now, it turns out that there's something fundamental about antibiotics

Resulta que hai algo fundamental sobre os antibióticos

which makes it different from other drugs,

que os fai distintos doutros fármacos,

which is that if I misuse antibiotics

e é que se uso antibióticos,

or I use antibiotics,

correcta ou incorrectamente,

not only am I affected but others are affected as well,

non só é cousa miña senón que afecta aos demais tamén,

in the same way as if I choose to drive to work

da mesma maneira que se escollo ir traballar en coche

or take a plane to go somewhere,

ou coller un avión para ir a algures,

that the costs I impose on others

o custo que impoño aos demais polo quecemento global,

through global climate change go everywhere,

distribúese por todas partes,

and I don't necessarily take these costs into consideration.

aínda que eu non teña este custo en conta necesariamente.

This is what economists might call a problem of the commons,

Na economía chamaríanlle a isto a traxedia dos bens comúns

and the problem of the commons is exactly

e é o mesmo problema que temos cos antibióticos,

what we face in the case of antibiotics as well:

that we don't consider —

que nós non temos en conta

and we, including individuals, patients,

—nós inclúe a todo individuo, pacientes,

hospitals, entire health systems —

hospitais, sistemas de saúde completos—

non temos en conta os custos que lles impoñemos aos demais

do not consider the costs that they impose on others

by the way antibiotics are actually used.

debido a como empregamos os antibióticos.

Now, that's a problem that's similar

É un problema semellante

to another area that we all know about,

ao que acontece noutro eido que ben coñecemos,

which is of fuel use and energy,

o consumo de combustible e o uso da enerxía,

and of course energy use

e, por suposto, o consumo de enerxía,

both depletes energy as well as

ademais de esgotar os recursos,

leads to local pollution and climate change.

causa contaminación local e cambio climático.

And typically, in the case of energy,

E, no caso da enerxía,

there are two ways in which you can deal with the problem.

hai dúas maneiras de atallar o problema.

One is, we can make better use of the oil that we have,

Unha é facer un mellor uso do petróleo que temos

and that's analogous to making better use

e, por analoxía, iso sería facer un mellor uso

of existing antibiotics,

dos antibióticos existentes.

and we can do this in a number of ways

Iso podémolo facer de distintas maneiras

that we'll talk about in a second,

das que falarei máis adiante

but the other option is the "drill, baby, drill" option,

pero a outra opción é a opción de "perfora, perfora",

which in the case of antibiotics is to go find new antibiotics.

que, no caso dos antibióticos, tradúcese en atopar novos antibióticos.

Now, these are not separate.

Estas opcións non están separadas.

They're related, because if we invest heavily

Van da man xa que, se investimos moito

in new oil wells,

en novos pozos petrolíferos,

we reduce the incentives for conservation of oil

reducimos o incentivo para a conservación do petróleo existente,

in the same way that's going to happen for antibiotics.

do mesmo xeito que ocorrerá cos antibióticos.

The reverse is also going to happen, which is that

No caso contrario sucederá que,

se empregamos os antibióticos axeitadamente,

if we use our antibiotics appropriately,

we don't necessarily have to make the investments

non necesariamente teremos que investir

in new drug development.

no desenvolvemento de novos fármacos.

And if you thought that these two were entirely,

Se pensabades que estabamos en completo

fully balanced between these two options,

equilibrio entre estas dúas opcións,

you might consider the fact that

en realidade estamos a xogar a un xogo.

this is really a game that we're playing.

The game is really one of coevolution,

O xogo da coevolución.

and coevolution is, in this particular picture,

e a coevolución dáse, nesta imaxe en particular,

between cheetahs and gazelles.

entre guepardos e gacelas.

Cheetahs have evolved to run faster,

Os guepardos evolucionaron para correr máis rápido

because if they didn't run faster,

xa que, se non o fixesen,

they wouldn't get any lunch.

non obterían comida ningunha.

Gazelles have evolved to run faster because

As gacelas evolucionaron para correr máis rápido

if they don't run faster, they would be lunch.

pois se non corresen máis rápido, elas serían a comida.

Now, this is the game we're playing against the bacteria,

Xogamos ao mesmo contra as bacterias,

except we're not the cheetahs,

salvo que nós non somos os guepardos,

we're the gazelles,

somos as gacelas,

and the bacteria would,

e, no que dura esta curta conferencia,

just in the course of this little talk,

as bacterias puideron

would have had kids and grandkids

ter fillos e netos, e achar como ser resistentes

and figured out how to be resistant

just by selection and trial and error,

por selección e ensaio e erro,

trying it over and over again.

intentándoo unha e outra vez.

Whereas how do we stay ahead of the bacteria?

Namentres, como lles ganamos a carreira as bacterias?

We have drug discovery processes,

Nós contamos con procesos para descubrir fármacos,

screening molecules,

analizamos moléculas,

we have clinical trials,

facemos probas clínicas,

and then, when we think we have a drug,

e, cando cremos ter un bo fármaco,

then we have the FDA regulatory process.

temos aínda o proceso regulador do FDA.

And once we go through all of that,

Despois de superar todo iso,

then we try to stay one step ahead

procuramos ir un paso por diante

of the bacteria.

das bacterias.

Now, this is clearly not a game that can be sustained,

Abofé que isto non é un xogo que poida prolongarse ou ganarse

or one that we can win

tan só innovando para ir por diante.

by simply innovating to stay ahead.

We've got to slow the pace of coevolution down,

Temos que retardar o proceso da coevolución

and there are ideas that we can borrow from energy

e hai ideas que podemos coller emprestadas do campo da enerxía

that are helpful in thinking about

que nos poden axudar a pensar

nas medidas que poderíamos tomar

how we might want to do this in the case

of antibiotics as well.

no caso dos antibióticos.

Now, if you think about how we deal with

Pensade, por exemplo, na xestión

energy pricing, for instance,

do prezo da enerxía.

we consider emissions taxes,

Temos uns impostos sobre as emisións de gases,

which means we're imposing the costs of pollution

onde se teñen en conta

os custos da contaminación,

on people who actually use that energy.

que recaen nas persoas

que consomen esa enerxía.

We might consider doing that for antibiotics as well,

Poderiamos contemplar

facer o mesmo cos antibióticos,

and perhaps that would make sure that antibiotics

o que quizais aseguraría

actually get used appropriately.

que se usan axeitadamente.

There are clean energy subsidies,

Tamén hai subsidios á enerxía limpa,

which are to switch to fuels which don't pollute as much

os cales permiten cambiar a combustibles

que no contaminan tanto

or perhaps don't need fossil fuels.

ou incluso para non utilizar combustibles fósiles.

Now, the analogy here is, perhaps we need

A analoxía neste caso é que quizais

to move away from using antibiotics,

temos que absternos de usar antibióticos,

and if you think about it, what are good substitutes for antibiotics?

e se vos poñedes a pensar, cales son bos substitutos dos antibióticos?

Well, turns out that anything that reduces

Pois resulta que,

calquera cousa que reduza

the need for the antibiotic would really work,

a necesidade de antibióticos sería eficaz.

so that could include improving hospital infection control

Por exemplo, mellorar o control das infeccións hospitalarias

or vaccinating people,

ou vacinar a xente,

particularly against the seasonal influenza.

sobre todo contra a gripe estacional.

And the seasonal flu is probably

A gripe estacional é probablemente

the biggest driver of antibiotic use,

o impulsor principal detrás do consumo de antibióticos,

both in this country as well as in many other countries,

tanto neste país coma en outros moitos,

and that could really help.

e iso realmente podería axudar.

A third option might include something like tradeable permits.

A terceira opción suporía algo parecido aos permisos comercializables.

And these seem like faraway scenarios,

Pode que parezan posibilidades remotas,

but if you consider the fact that we might not

pero se se tivera en conta o feito de que quizais

have antibiotics for many people who have infections,

non hai antibióticos suficientes para todos os infectados,

we might consider the fact that we might

poderiamos contemplar asignar

want to allocate who actually gets to use

algúns destes antibióticos a uns pacientes e non a outros,

some of these antibiotics over others,

and some of these might have to be on the basis of clinical need,

en función das necesidades clínicas,

but also on the basis of pricing.

pero tamén do prezo do tratamento.

And certainly consumer education works.

Educar aos consumidores sen dúbida funciona.

Very often, people overuse antibiotics

Moitas veces, a xente abusa dos antibióticos

or prescribe too much without necessarily

ou estanse a receitar de máis, sen razón.

knowing that they do so,

and feedback mechanisms

Tamén sabemos que, ao igual que no caso da enerxía,

have been found to be useful,

os mecanismos de retroalimentación poden ser útiles.

both on energy —

When you tell someone that they're using

Se a un o avisan de que está a consumir

a lot of energy during peak hour,

moita enerxía durante a hora punta,

they tend to cut back,

un mesmo procura diminuír o seu consumo,

and the same sort of example has been performed

e o mesmo feito dáse até no caso dos antibióticos.

even in the case of antibiotics.

A hospital in St. Louis basically would put up

Un hospital de St. Louis acostumaba poñer nun taboleiro

on a chart the names of surgeons

os nomes dos cirurxiáns ordenados

in the ordering of how much antibiotics they'd used

por cantos antibióticos utilizaran no mes anterior

in the previous month,

and this was purely an informational feedback,

e só o facían pola retroalimentación informativa,

there was no shaming,

sen intención de humillalos,

but essentially that provided some information back

pero, en esencia, proporcionábanlles

to surgeons that maybe they could rethink

aos cirurxiáns unha información

how they were using antibiotics.

coa que podían reflexionar

sobre como usaban os antibióticos.

Now, there's a lot that can be done

Aínda queda moito por facer

on the supply side as well.

en canto á subministración tamén.

If you look at the price of penicillin,

Se miran os prezos da penicilina,

the cost per day is about 10 cents.

o custo por día é duns 10 céntimos.

It's a fairly cheap drug.

É un fármaco bastante barato.

If you take drugs that have been introduced since then —

Os fármacos introducidos posteriormente

linezolid or daptomycin —

—a linezolida e a daptomicina—

those are significantly more expensive,

son moito máis caros.

so to a world that has been used to paying 10 cents a day for antibiotics,

Nun mundo que está afeito a pagar 10 céntimos ao día por un antibiótico,

the idea of paying 180 dollars per day

a idea de pagar 180 dólares ao día semella moito

seems like a lot.

But what is that really telling us?

Que nos pode dicir isto?

That price is telling us

O prezo estanos a mostrar que no futuro

that we should no longer

take cheap, effective antibiotics as a given

no imos ter antibióticos baratos dos que botar man.

into the foreseeable future,

and that price is a signal to us

Ese prezo é un sinal

that perhaps we need to be paying

de que ao mellor temos que prestar

much more attention to conservation.

moita máis atención ao aforro.

That price is also a signal

Ese prezo tamén é un sinal

that maybe we need to start looking at other technologies,

de que ao mellor é hora de comezar

a botarlles unha ollada

in the same way that gasoline prices are a signal

a outras tecnoloxías,

do mesmo xeito que o prezo da gasolina

and an impetus, to, say,

é un sinal e un estímulo

the development of electric cars.

para desenvolver coches eléctricos.

Prices are important signals

Os prezos son sinais importantes

and we need to pay attention,

e necesitamos prestarlles atención,

but we also need to consider the fact that

pero tamén teñan en conta que,

although these high prices seem unusual for antibiotics,

aínda que os prezos nos parezan insólitos para un antibiótico,

they're nothing compared to the price per day

non son nada comparados co prezo diario

dalgúns fármacos contra o cancro

of some cancer drugs,

which might save a patient's life only for a few months or perhaps a year,

que salvan a vida do paciente durante algúns meses ou quizais un ano,

whereas antibiotics would potentially

namentres que o antibiótico podería

save a patient's life forever.

salvarlle a vida ao paciente para sempre.

So this is going to involve

Polo tanto, todo isto esixe un cambio

a whole new paradigm shift,

cara a un novo paradigma,

and it's also a scary shift because

un cambio que dá medo,

in many parts of this country,

xa que en moitos lugares deste país,

in many parts of the world,

e en moitos outros lugares do mundo,

the idea of paying 200 dollars

a idea de pagar 200 dólares

for a day of antibiotic treatment

por un día de tratamento con antibióticos

is simply unimaginable.

é simplemente inimaxinable.

So we need to think about that.

Así que debemos pensar niso.

Now, there are backstop options,

Agora ben, hai outras opcións,

which is other alternative technologies

outras tecnoloxías alternativas

that people are working on.

nas que se está a traballar.

It includes bacteriophages, probiotics,

Entre outras, os bacteriófagos, os probióticos,

quorum sensing, synbiotics.

a percepción de quórum e os simbióticos.

Now, all of these are useful avenues to pursue,

Todos son bos camiños para explorar

and they will become even more lucrative

e volveranse aínda máis lucrativos

when the price of new antibiotics starts going higher,

cando o prezo dos novos antibióticos comece a subir.

and we've seen that the market does actually respond,

Xa vimos que o mercado responde

and the government is now considering

e o goberno agora está a pensar

ways of subsidizing new antibiotics and development.

en formas de subvencionar

novos antibióticos e o seu desenvolvemento.

But there are challenges here.

Aínda así existen desafíos.

We don't want to just throw money at a problem.

Non podemos limitarnos a meterlle cartos ao problema.

What we want to be able to do

is invest in new antibiotics

Queremos ser capaces de investir en novos antibióticos e tamén

in ways that actually encourage

en maneiras que promovan

appropriate use and sales of those antibiotics,

o uso e venda adecuados deses antibióticos,

and that really is the challenge here.

e ese é o auténtico desafío.

Now, going back to these technologies,

Volvendo á tecnoloxía,

you all remember the line from that famous

todos recordan esa frase dunha coñecida película sobre dinosauros:

dinosaur film, "Nature will find a way."

So it's not as if these are permanent solutions.

Isto non son solucións permanentes.

We really have to remember that, whatever the technology might be,

Debemos recordar que, calquera que sexa a tecnoloxía,

that nature will find some way to work around it.

a natureza atopará o xeito de contrarrestala.

You might think, well, this is just a problem

Se cadra estades a pensar

just with antibiotics and with bacteria,

que só é un problema cos antibióticos e as bacterias,

but it turns out that we have the exact same

pero dáse o feito de que temos exactamente

identical problem in many other fields as well,

o mesmo problema en moitos outros eidos,

with multidrug-resistant tuberculosis,

coa tuberculose multirresistente (MDR TB),

which is a serious problem in India and South Africa.

un grave problema na India e Suráfrica.

Thousands of patients are dying because

Milleiros de pacientes morren porque

the second-line drugs are so expensive,

os fármacos de segunda liña son moi caros

and in some instances, even those don't work

e, ás veces, nin sequera funcionan

and you have XDR TB.

e ademais temos a XDR TB.

Viruses are becoming resistant.

Os virus vólvense resistentes.

Agricultural pests. Malaria parasites.

Están as pragas na agricultura.

Os parasitos da malaria.

Right now, much of the world depends on

Hoxe en día

a meirande parte do mundo

one drug, artemisinin drugs,

depende dun medicamento,

os derivados da artemisina,

essentially to treat malaria.

fundamentalmente para o tratamento da malaria.

Resistance to artemisinin has already emerged,

A resistencia á artemisina xa chegou

and if this were to become widespread,

e se comezara a espallarse, poría en risco

that puts at risk

o único fármaco co cal tratamos a malaria con eficacia

the single drug that we have to treat malaria around the world

in a way that's currently safe and efficacious.

e sen perigo, en todo o mundo.

Mosquitos develop resistance.

Os mosquitos vólvense resistentes.

If you have kids, you probably know about head lice,

Se teñen fillos, seguro que

lles soarán os piollos,

and if you're from New York City,

e se son da cidade de Nova York,

I understand that the specialty there is bedbugs.

teño entendido que alí a especialidade son as chinches.

So those are also resistant.

Pois tamén son resistentes.

And we have to bring an example from across the pond.

Tamén temos un exemplo no outro lado do charco.

Turns out that rats are also resistant to poisons.

Resulta que as ratas tamén son resistentes ao veleno.

Now, what's common to all of these things is

O que todos estes casos teñen en común

the idea that we've had these technologies

é a idea de que temos estas tecnoloxías

to control nature only for the last 70, 80 or 100 years

para controlar a natureza desde hai só 70, 80 ou 100 anos

and essentially in a blink,

e, nun abrir e pechar de ollos,

we have squandered our ability to control,

estragamos a nosa capacidade para controlala

because we have not recognized

porque non nos demos conta

that natural selection and evolution was going to find

de que a selección natural e a evolución ían achar

a way to get back,

como atopar un camiño

and we need to completely rethink

e temos que repensar por completo

how we're going to use

como vamos empregar as medidas

measures to control biological organisms,

para controlar os organismos biolóxicos

and rethink how we incentivize

e reformular como incentivamos

the development, introduction,

o desenvolvemento e a introdución,

in the case of antibiotics prescription,

neste caso a prescrición dos antibióticos,

and use of these valuable resources.

e o uso deste valioso recurso.

And we really now need to start thinking about them

Realmente necesitamos comezar a consideralos

as natural resources.

como recursos naturais.

And so we stand at a crossroads.

Agora estamos nunha encrucillada.

An option is to go through that rethinking

Unha opción lévanos á reformulación

and carefully consider incentives

e a consideración precavida dos incentivos

to change how we do business.

para mudar o modelo de negocio.

The alternative is

A alternativa é

a world in which even a blade of grass

un mundo no que ata unha folla de herba

is a potentially lethal weapon.

pode ser unha arma letal.

Thank you.

Grazas.

(Aplausos)

(Applause)