Ramanan Laxminarayan: How Did A Medical Miracle Turn Into A Global Threat? Antibiotics save lives, but we rely on them too much. Eventually, the drugs may stop working. Economist Ramanan Laxminarayan asks us to think twice before reaching for this double-edged resource.

How Did A Medical Miracle Turn Into A Global Threat?

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So on the show today, we're talking about finite resources. And here's a story about something we don't normally think of as a resource at all. We heard about it from Ramanan Laxminarayan. He's an economist who studies the patterns of disease. And the story begins in late December 1940, in Oxford, England.

RAMANAN LAXMINARAYAN: And there's this policeman who shows up at the infirmary in Oxford. And on his day off from work, he had been scratched by a rose thorn, apparently.

RAZ: The policeman was a guy named Albert Alexander, and that little scratch had turned into a nasty infection.

LAXMINARAYAN: His entire side of his cheek is infected and swollen. His eyes were so badly infected that they had to take his eyes out. There's a giant abscess on his face.

RAZ: Now, remember, back in 1940, infections were a leading cause of death. Most of the soldiers in major wars didn't die from being shot, they died from infected wounds.

LAXMINARAYAN: If someone had an infection from a simple scratch, they could just wait it out. There was a good chance of dying.

RAZ: But it just so happened that at a lab not too far from this particular hospital in Oxford, where Albert Alexander wound up, researchers were working on an experimental new drug...

LAXMINARAYAN: Which was capable of killing bacteria.


RAZ: It had been discovered purely by accident a couple of years earlier that was made from a type of mold. But the researchers didn't know if the drug was safe enough to use on a human being. It had never been tested. And by chance, they found out about Albert Alexander.

LAXMINARAYAN: And they figured this person was going to die anyway and so why not try out this drug? And they give him this drug. The first day, already, he starts looking a little better. His appetite returns. Second day, he looks a whole lot better.

RAZ: Day three, even better. Day four, much better.

LAXMINARAYAN: Fifth day, it looks like this man may actually live, and then they run out of penicillin.

RAZ: Penicillin - the very first antibiotic.

So they run out of penicillin, and then what?


RAZ: Wow.

LAXMINARAYAN: But you have to remember, this was such a remarkable experiment to have even worked out because somehow this drug worked in this patient and opened up this entire era of medicine. Everything that we know as modern medicine really goes back to that particular day, when Albert Alexander lived because of penicillin.

RAZ: And that was the start of the antibiotics revolution.

LAXMINARAYAN: The fact that you could keep an infection at bay from the body meant that you could now perform surgeries. You could perform long surgeries. And because of that, you could have transplants. You could have a root canal. All of these were made possible by the fact that we have antibiotics.

RAZ: We're talking about basically, a miracle drug, I mean, arguably one of the most effective and important medical advancements in human history.


RAZ: Antibiotics completely transformed human life spans overnight, but the antibiotics revolution is starting to unravel. According to the Centers for Disease Control, twice as many Americans now die each year from infections that can't be cured within antibiotics than from HIV-AIDS. And that problem is getting worse.

LAXMINARAYAN: In fact, even as recently as, say, 15 or 18 years ago, I don't recall actually knowing a patient with a resistant infection. But what has happened in the last 10 years has been a remarkable increase in the actual number of people who are dying or are not able to get better because they carry a resistant infection.

RAZ: And by the middle this century, more people will die from infections than from cancer if the problem isn't solved. It would be like winding the clock back to 1940. So the question is how did the miracle drug turn into a global health threat? Well, the short answer is we've been overusing them on humans and animals. And the more we use antibiotics, the more opportunities bacteria have to develop resistance.

LAXMINARAYAN: And in some instances, some antibiotics have stopped working entirely. We have used antibiotics in many insistences inappropriately. We've used them on farms, presumably to keep animals healthy, but really to help them get fatter a little faster. To save a few pennies per pound of meat, we've squandered what are really the crown jewels of modern medicine.

RAZ: Which is why Ramanan says we need to think of antibiotics in a completely different way. We need to think of them like we think of oil or water - as a resource that needs to be protected. Ramanan explained his idea from the TED stage.


LAXMINARAYAN: 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 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. 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.


RAZ: I mean, the amazing thing about all this is that there no alternatives to antibiotics, right, like in terms of effectiveness? I mean, we have to solve this problem or we're in big trouble.

LAXMINARAYAN: You're absolutely right, and this is what really worries me about this problem. The only alternatives we have are to prevent the infection with vaccines or infection control or what have you. But honestly, we really don't have a substitute for antibiotics. And no one has figured out that, say, in 50 years from now, we won't need antibiotics because we have X. Maybe X will appear, but right now, no one is able to see through to see what this X really will be. We really don't have a substitute for antibiotics.


LAXMINARAYAN: Now, this is clearly not a game that can be sustained or one that we can win by simply innovating to stay ahead. 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'd 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. And certainly consumer education works. Very often, people overuse antibiotics without necessarily - or prescribed 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.


RAZ: We can't stop using antibiotics. It's not an option. That is not an option to solve this problem. It has to be about dramatically reducing how much we use them.

LAXMINARAYAN: It has to be about reducing how we use them, changing how we use them, being clever about how we use them. So for instance, just imagine if we had a technology which - you know, it was a pill that you ingested with the antibiotic that the minute the antibiotic had done its work in the site of infection, that this pill would then absolve the remaining antibiotic so that the antibiotic wasn't running around willy-nilly around your body killing bacteria and creating resistance. That would dramatically reduce the collateral damage that the antibiotic will do.

RAZ: Yeah, I had to take antibiotics for 10 days. But after, you know, 48 hours, I felt fine. And probably after five days, it was gone, but you still have to take it for 10 days.

LAXMINARAYAN: You know, the history of that is very interesting. The earliest antibiotics were never actually tried-out in clinical trials of the kind we have today because most of our antibiotics predate the laws that required the randomized trials. So much of what we know about how long antibiotic therapy needs to be is by trial-and-error that goes back to Albert Alexander.

RAZ: Wow.

LAXMINARAYAN: So Albert Alexander, five days didn't work for him, so they didn't want to take a chance. They said 10 or 14 days of therapy, and that's what you have to go with.

RAZ: And that may be contributing to the problem - that we are taking it for too long.

LAXMINARAYAN: Absolutely. Now, you've got to remember here on the one hand, the main actor in our society who is handing out antibiotics is a doctor.

RAZ: Yeah.

LAXMINARAYAN: The doctor cares about the patient that's sitting in front of him or her. And if she sees a patient with some likelihood that the infection may come back in five days or six days if she didn't treat for long enough, then, you know, she just wants to provide an antibiotic for 10 days, or maybe even 14 days because that's what protects the patient. But that's not what protects the rest of society. But the doctor is not hired to protect the rest of society. She's there to protect the patient, and that's what she does.


LAXMINARAYAN: We've had these technologies to control nature only for the last 70, 80 or 100 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 - of these valuable resources. Thank you.


RAZ: Ramanan Laxminarayan, he's an economist who studies the patterns of disease and directs the Center for Disease, Dynamics, Economics and Policy. You can see his entire talk at ted.com.


RAZ: Coming up on the show, a future without oil that doesn't have to be like a "Mad Max" movie. I'm Guy Raz, and you're listening to the TED Radio Hour from NPR.

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