WEBVTT

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The first patient to ever be 
treated with an antibiotic

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was a policeman in Oxford.

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On his day off from work,

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

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That small scratch became infected.

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Over the next few days, 
his head was swollen

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with abscesses,

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and in fact his eye was so infected

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that they had to take it out,

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and by February of 1941,

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this poor man was on the verge of dying.

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He was at Radcliffe Infirmary in Oxford,

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and fortunately for him,

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a small team of doctors

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led by a Dr. Howard Florey

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had managed to synthesize

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a very small amount of penicillin,

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a drug that had been discovered

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12 years before by Alexander Fleming

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but had never actually been 
used to treat a human,

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

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

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but Florey and his team figured

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

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on someone who was going to die anyway.

NOTE Paragraph

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So they gave Albert Alexander,

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this Oxford policeman, the drug,

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and within 24 hours,

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he started getting better.

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His fever went down, 
his appetite came back.

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Second day, he was doing much better.

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They were starting to 
run out of penicillin,

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so what they would do 
was run with his urine

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

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and give it back to him,

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and that worked.

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Day four, well on the way to recovery.

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This was a miracle.

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Day five, they ran out of penicillin,

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and the poor man died.

NOTE Paragraph

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So that story didn't end that well,

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but fortunately for 
millions of other people,

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

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who was again dying of a sepsis,

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and within just six days, you can see,

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recovered thanks to this 
wonder drug, penicillin.

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Millions have lived,

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and global health has been transformed.

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Now, antibiotics have been used

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for patients like this,

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but they've also been 
used rather frivolously

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in some instances,

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for treating someone 
with just a cold or the flu,

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which they might not have 
responded to an antibiotic,

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and they've also been 
used in large quantities

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sub-therapeutically, which
means in small concentrations,

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to make chicken and hogs grow faster.

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

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we've spent a lot of 
antibiotics on animals,

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not for treatment, not for sick animals,

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but primarily for growth promotion.

NOTE Paragraph

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Now, what did that lead us to?

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Basically, the massive use of antibiotics

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around the world

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has imposed such large
selection pressure on bacteria

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that resistance is now a problem,

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because we've now selected for just

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the resistant bacteria.

NOTE Paragraph

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

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you've seen this in every magazine

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that you come across,

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but I really want you to appreciate

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the significance of this problem.

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This is serious.

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

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Acinetobacter is a nasty hospital bug,

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and carbapenem is pretty much

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the strongest class of antibiotics

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that we can throw at this bug.

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And you can see in 1999

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this is the pattern of resistance,

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mostly under about 10 percent
across the United States.

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Now watch what happens 
when we play the video.

NOTE Paragraph

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So I don't know where you live,

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

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than it was in 1999,

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and that is the problem of antibiotic resistance.

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It's a global issue

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affecting both rich and poor countries,

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

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isn't this really just a medical issue?

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

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if we taught patients how 
not to demand antibiotics,

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perhaps this really wouldn't be an issue,

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and maybe the pharmaceutical companies

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should be working harder to develop

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more antibiotics.

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

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which makes it different from other drugs,

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which is that if I misuse antibiotics

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or I use antibiotics,

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

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

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or take a plane to go somewhere,

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that the costs I impose on others

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through global climate change go everywhere,

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

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

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and the problem of the commons is exactly

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what we face in the case 
of antibiotics as well:

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that we don't consider —

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and we, including individuals, patients,

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hospitals, entire health systems —

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do not consider the costs 
that they impose on others

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by the way antibiotics are actually used.

NOTE Paragraph

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Now, that's a problem that's similar

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to another area that we all know about,

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which is of fuel use and energy,

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and of course energy use

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both depletes energy as well as

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leads to local pollution 
and climate change.

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And typically, in the case of energy,

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

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

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and that's analogous to making better use

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of existing antibiotics,

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and we can do this in a number of ways

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that we'll talk about in a second,

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

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

NOTE Paragraph

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Now, these are not separate.

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They're related, because if we invest heavily

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in new oil wells,

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we reduce the incentives 
for conservation of oil

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

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The reverse is also going 
to happen, which is that

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if we use our antibiotics appropriately,

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we don't necessarily have 
to make the investments

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in new drug development.

NOTE Paragraph

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And if you thought that these two were entirely,

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fully balanced between these two options,

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you might consider the fact that

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this is really a game that we're playing.

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The game is really one of coevolution,

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and coevolution is, in 
this particular picture,

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between cheetahs and gazelles.

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Cheetahs have evolved to run faster,

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because if they didn't run faster,

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they wouldn't get any lunch.

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Gazelles have evolved to run faster because

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

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

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except we're not the cheetahs,

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we're the gazelles,

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and the bacteria would,

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just in the course of this little talk,

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would have had kids and grandkids

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and figured out how to be resistant

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just by selection and trial and error,

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trying it over and over again.

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Whereas how do we stay 
ahead of the bacteria?

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We have drug discovery processes,

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screening molecules,

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we have clinical trials,

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and then, when we think we have a drug,

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then we have the FDA regulatory process.

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And once we go through all of that,

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then we try to stay one step ahead

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of the bacteria.

NOTE Paragraph

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

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or one that we can win

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by simply innovating to stay ahead.

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

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and there are ideas that we 
can borrow from energy

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that are helpful in thinking about

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how we might want to do this in the case

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of antibiotics as well.

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Now, if you think about how we deal with

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energy pricing, for instance,

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we consider emissions taxes,

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which means we're imposing 
the costs of pollution

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on people who actually use that energy.

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We might consider doing that for antibiotics as well,

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and perhaps that would make sure that antibiotics

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actually get used appropriately.

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There are clean energy subsidies,

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

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or perhaps don't need fossil fuels.

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Now, the analogy here is, perhaps we need

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to move away from using antibiotics,

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

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Well, turns out that anything that reduces

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the need for the antibiotic would really work,

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so that could include improving
hospital infection control

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or vaccinating people,

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particularly against 
the seasonal influenza.

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And the seasonal flu is probably

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the biggest driver of antibiotic use,

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

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and that could really help.

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A third option might include
something like tradeable permits.

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And these seem like faraway scenarios,

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but if you consider the 
fact that we might not

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have antibiotics for many 
people who have infections,

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we might consider the fact that we might

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want to allocate who actually gets to use

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some of these antibiotics over others,

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

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but also on the basis of pricing.

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And certainly consumer education works.

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Very often, people overuse antibiotics

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or prescribe too much without necessarily

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knowing that they do so,

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and feedback mechanisms

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have been found to be useful,

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both on energy —

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When you tell someone that they're using

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a lot of energy during peak hour,

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they tend to cut back,

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and the same sort of example has been performed

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even in the case of antibiotics.

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A hospital in St. Louis basically would put up

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on a chart the names of surgeons

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in the ordering of how much antibiotics they'd used

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in the previous month,

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and this was purely an 
informational feedback,

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there was no shaming,

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but essentially that provided 
some information back

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to surgeons that maybe they could rethink

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how they were using antibiotics.

NOTE Paragraph

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Now, there's a lot that can be done

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on the supply side as well.

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If you look at the price of penicillin,

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the cost per day is about 10 cents.

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It's a fairly cheap drug.

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If you take drugs that have
been introduced since then —

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linezolid or daptomycin —

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those are significantly more expensive,

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

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the idea of paying 180 dollars per day

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seems like a lot.

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But what is that really telling us?

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That price is telling us

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that we should no longer

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take cheap, effective 
antibiotics as a given

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into the foreseeable future,

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and that price is a signal to us

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that perhaps we need to be paying

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much more attention to conservation.

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That price is also a signal

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that maybe we need to start
looking at other technologies,

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in the same way that 
gasoline prices are a signal

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and an impetus, to, say,

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the development of electric cars.

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Prices are important signals

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and we need to pay attention,

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but we also need to consider the fact that

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although these high prices
seem unusual for antibiotics,

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they're nothing compared to the price per day

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of some cancer drugs,

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

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whereas antibiotics would potentially

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save a patient's life forever.

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So this is going to involve

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a whole new paradigm shift,

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and it's also a scary shift because

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in many parts of this country,

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in many parts of the world,

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the idea of paying 200 dollars

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for a day of antibiotic treatment

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is simply unimaginable.

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So we need to think about that.

NOTE Paragraph

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Now, there are backstop options,

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which is other alternative technologies

00:11:18.436 --> 00:11:19.630
that people are working on.

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It includes bacteriophages, probiotics,

00:11:22.282 --> 00:11:26.330
quorum sensing, synbiotics.

NOTE Paragraph

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Now, all of these are useful avenues to pursue,

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and they will become even more lucrative

00:11:31.979 --> 00:11:35.060
when the price of new 
antibiotics starts going higher,

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

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and the government is now considering

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ways of subsidizing new 
antibiotics and development.

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But there are challenges here.

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

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What we want to be able to do

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is invest in new antibiotics

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in ways that actually encourage

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appropriate use and sales of those antibiotics,

00:11:56.824 --> 00:11:59.287
and that really is the challenge here.

NOTE Paragraph

00:11:59.287 --> 00:12:01.616
Now, going back to these technologies,

00:12:01.616 --> 00:12:03.979
you all remember the line from that famous

00:12:03.979 --> 00:12:06.205
dinosaur film, "Nature will find a way."

00:12:06.205 --> 00:12:09.524
So it's not as if these are 
permanent solutions.

00:12:09.524 --> 00:12:13.610
We really have to remember that,
whatever the technology might be,

00:12:13.610 --> 00:12:16.486
that nature will find some 
way to work around it.

NOTE Paragraph

00:12:16.486 --> 00:12:18.557
You might think, well, 
this is just a problem

00:12:18.557 --> 00:12:21.301
just with antibiotics and with bacteria,

00:12:21.301 --> 00:12:23.247
but it turns out that we 
have the exact same

00:12:23.247 --> 00:12:25.981
identical problem in 
many other fields as well,

00:12:25.981 --> 00:12:28.933
with multidrug-resistant tuberculosis,

00:12:28.933 --> 00:12:32.495
which is a serious problem 
in India and South Africa.

00:12:32.495 --> 00:12:34.282
Thousands of patients are dying because

00:12:34.282 --> 00:12:36.116
the second-line drugs are so expensive,

00:12:36.116 --> 00:12:38.343
and in some instances, even those don't work

00:12:38.343 --> 00:12:40.413
and you have XDR TB.

00:12:40.413 --> 00:12:42.224
Viruses are becoming resistant.

00:12:42.224 --> 00:12:45.390
Agricultural pests. Malaria parasites.

00:12:45.390 --> 00:12:47.173
Right now, much of the world depends on

00:12:47.173 --> 00:12:50.870
one drug, artemisinin drugs,

00:12:50.870 --> 00:12:52.826
essentially to treat malaria.

00:12:52.826 --> 00:12:55.413
Resistance to artemisinin has already emerged,

00:12:55.413 --> 00:12:57.767
and if this were to become widespread,

00:12:57.767 --> 00:12:59.115
that puts at risk

00:12:59.115 --> 00:13:02.006
the single drug that we have to 
treat malaria around the world

00:13:02.006 --> 00:13:05.220
in a way that's currently 
safe and efficacious.

00:13:05.220 --> 00:13:07.018
Mosquitos develop resistance.

00:13:07.018 --> 00:13:09.255
If you have kids, you probably 
know about head lice,

00:13:09.255 --> 00:13:10.968
and if you're from New York City,

00:13:10.968 --> 00:13:13.701
I understand that the 
specialty there is bedbugs.

00:13:13.701 --> 00:13:15.956
So those are also resistant.

00:13:15.956 --> 00:13:18.835
And we have to bring an
example from across the pond.

00:13:18.835 --> 00:13:21.190
Turns out that rats are 
also resistant to poisons.

NOTE Paragraph

00:13:21.190 --> 00:13:23.891
Now, what's common 
to all of these things is

00:13:23.891 --> 00:13:26.597
the idea that we've had these technologies

00:13:26.597 --> 00:13:31.218
to control nature only for 
the last 70, 80 or 100 years

00:13:31.218 --> 00:13:34.246
and essentially in a blink,

00:13:34.246 --> 00:13:36.797
we have squandered our ability to control,

00:13:36.797 --> 00:13:39.288
because we have not recognized

00:13:39.288 --> 00:13:42.100
that natural selection and 
evolution was going to find

00:13:42.100 --> 00:13:43.274
a way to get back,

00:13:43.274 --> 00:13:45.323
and we need to completely rethink

00:13:45.323 --> 00:13:47.666
how we're going to use

00:13:47.666 --> 00:13:50.760
measures to control biological organisms,

00:13:50.760 --> 00:13:54.224
and rethink how we incentivize

00:13:54.224 --> 00:13:56.450
the development, introduction,

00:13:56.450 --> 00:13:59.118
in the case of antibiotics prescription,

00:13:59.118 --> 00:14:02.890
and use of these valuable resources.

00:14:02.890 --> 00:14:05.270
And we really now need to 
start thinking about them

00:14:05.270 --> 00:14:07.228
as natural resources.

00:14:07.228 --> 00:14:09.466
And so we stand at a crossroads.

00:14:09.466 --> 00:14:12.625
An option is to go through that rethinking

00:14:12.625 --> 00:14:14.438
and carefully consider incentives

00:14:14.438 --> 00:14:16.992
to change how we do business.

00:14:16.992 --> 00:14:19.253
The alternative is

00:14:19.253 --> 00:14:22.336
a world in which even a blade of grass

00:14:22.336 --> 00:14:24.765
is a potentially lethal weapon.

NOTE Paragraph

00:14:24.765 --> 00:14:26.565
Thank you.

NOTE Paragraph

00:14:26.565 --> 00:14:29.300
(Applause)