In this episode of the Making Sense podcast, Sam Harris speaks with Matt McCarthy about his book "Superbugs: The Race to Stop an Epidemic." They discuss the problem of drug resistant bacteria, fungi, parasites, and viruses, and the failure of the pharmaceutical industry to keep pace with evolution.
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This is an unofficial transcript meant for reference. Accuracy is not guaranteed.
Welcome to the making sense podcast this is SAM Harris no housekeeping today, going jump right into it.
Today, I'm speaking with Matt Mccarthy,.
Man is an infectious disease doctor and a professor of medicine at Cornell, where he also serves on the ethics committee.
His writing has appeared in the New England Journal of Medicine, sports illustrated slate and other journals. He is the author of several books and his latest is super bugs the race to
stop an epidemic and that's what we talked about today
the problem that many of the drugs we used to treat infectious disease are now failing
and will always be, failing we're in a perpetual arms race against evolution,
and the emergence of new bugs that are immune systems have never seen
Quite amazingly is a problem that is receiving very little attention
and yet is on the short list of things that could utterly transform the character of human life very much for the worse
it's also on the short list of problems for which the market appears to offer no solution. As we will discuss
now without further delay. I bring you Matt Mccarthy,
I am here with Matt Mccarthy Matt, thanks for coming on the podcast. Thanks for having me.
So you have written a book that could be terrified.
You trying to be as helpful as you can be around. But God this topic is just
It's brutal, I mean this could be my own, ah germ phobia creeping in here, but ah you have written a book superbugs the rays to stop an epidemic, and this is a topic. I've been worrying about for a long time, and I think ever since that the first Ebola
air and some of the books that followed and now we're talking what that with, must been
two. Ninety nine or thereabouts. Maybe earlier when Non member Laurie Garrett wrote a big book about the prospect of emerging pandemics yeah we jump into the topic, gotten tell us how you got into infectious disease and just what
your focus has been yeah. Well, I'm glad that you've been worrying about this for a while, because not enough people have been thinking about super bugs. I think the first thing is useful: to define the term some people say that drug resistant back to
very, are super bugs, but I take a much broader look at it and say that we're really
talking about our drug resistant, fungi and
sites and viruses and all kinds of living, things that can come and attack us.
An. You know, writing this book. I wasn't trying to freak people out, but I think that has been
sort of fallout. Is that people read this and go? Oh man. This is a big deal
And those of us in infectious diseases have been trying to sound
alarm about this. For a while, you know the world
organization just came out and said that super bugs are going
a bigger killer than heart disease and cancer by two thousand and fifty,
and so you know how I got into this. It wasn't
something that I had always dreamed of. Being an infectious disease specialist. I was first,
medical student at Harvard in two thousand and three, and I heard a lecture
young and charismatic infectious disease doctor named Paul farmer
all right, yeah yeah, you know he's traveled to Haiti and all over the world bringing drugs to people who couldn't afford them. Bringing antibiotics and HIV medicines and tuberculosis medicines to people, and I just fell under his sway- and I said
this is the guy. I want to do what he does and six months later I found myself in western Africa
hunting for the Ebola virus, and
to become an infectious disease doctor, and so that was fifteen years ago, and so that you know sort of launched me in this.
Career of trying to find
it's going to be the next big pandemic. What's going to be the thing that gets to us and how do we attack that and how do we come up with treatments to stave off the next big thing? Yeah I mean one problem: is that
many of us have for gotten, or we never knew in fact how scary it was to live in a world where infectious diseases were ascendant. We have for gotten what it's like for people to routinely die from tetanus and other wound infections, or
You know either whole generations of people were moving to warmer climates. You know, however, in effectually to try to mitigate their tuberculosis and you know which would kill them anyway, and we just we lived in a world leader for the the longest time for ever. Wear
It was just simply no guarantee or even promise that infections could be reliably.
Treated, and then we had this fundamental breakthrough in which you detail in your book I mean penicillin was the first widely available antibiotic.
And it really ushered in a golden age, when you could cure, you could expect to cure you all of these invisible agents of death, and we seem to have.
Taking it for granted up to the point where now we have fallen out of that, that happy conditioned well, you nailed it. I mean.
This is the thing that most people don't realize is the luxury we have of antibiotics. As you said, penicillin
ushered in the golden era of the 1950s, where every month or
Do we were pumping out a new life saving drug and the life expectancy ballooned because of all of these new drugs, and then what happened was
number of prominent scientists. Nobel laureates came out and said: you know we got this infectious disease thing kicked
it's time to move on to more pressing matters like heart, disease and cancer, and the pharmaceutical industry responded and started. Making chemotherapy drugs and blood thinners and all of these lucrative things, just as the super bugs were starting to mutate and to evolve and to become resistant to our treatments, and so now we're finding that as we're. Finally, paying attention to this issue, we're behind the eight ball in a sense because we're playing catch up, the drugs aren't working as well as they used to
and we're scrambling to find the next generation of life saving drugs. You know I'm reminded of this every single day when I walk into the hospital. The first place I go is the emergency room and I meet the patients who have these drug resistant infections and that's actually. What led me to write this book is that you know people have talked about super bugs before they talked about the policy about the science behind it all of the stuff sort of at a thirty thousand foot view. But what I was interested in with the patient stories and the lives that are completely derailed by these.
Things and the fact that the pharmaceutical industry is losing interest in making new antibiotics is devastating for tens of thousands of people and so
you know, I'm trying to raise awareness, but also say here's how we got in this mess and here's how we get out of it. So it let's talk about that. We'll talk about the the ways in which the the business model of the pharmaceutical industry is not helping us here in the market is not helping us here, but
before we get there. Let's just talk about them and the basic science. What we have is a really could have been foreseen based on evolutionary principles in a week. This isn't service surprising that we have bugs that can mutate and become resistant to the treatments we devised. For
and again, the reminders of this happening are everywhere more recording this. On a Monday. Yesterday, the front page of the Sunday New York Times had
the story on urinary tract infections, showing antibiotic resistance to a surprising degree, in something like thirty percent or resistant to most antibiotics. At this point, it really is a pressing concern
But it's not just a matter of bugs evolving
and getting around or antibiotics. It's also just the fact that there are so called super
bugs everywhere as yet on encountered by us, because the note there, bacteria in the soil and elsewhere, which the army in immune system hasn't devised, any response to and our
drugs can't anticipate, and so we will be. You know whether they mutate or not. We will are very likely to encounter so called super bugs in the future
Absolutely right, and one of the big problems we have is how doctors and scientists talk about these superbugs. You mentioned that front page science times article. I know the guy who wrote that piece because he's interviewed me before and you know one of the quotes from that article is that this level of of antibiotic resistance is shocking, and I read that and I thought shocking to who, because doctors know this and scientists know this, but if this is shocking to the lay public. That's because we
You haven't done a good enough job of explaining exactly how this is happening. But you know we just had a new roll over with first year, doctors who start in July and everyone,
one of them knows by the third day of work that the antibiotics that they used in medical
cool are no longer working. Then I got to use a new crop of drugs just to treat people and that's because the bacteria are evolving, as you mentioned, and they're coming up with these ingenious.
Ways to destroy the antibiotics that we've relied upon for a generation. One of the things they do is they make these things called e flux, pumps which are like microscopic vacuum cleaners and they suck up antibiotic
and they spit him out, and then they use these enzymes that can chop up antibiotics and so what we do and what my research is is we
look for new ways to fool the bacteria, and so one thing we found for exam.
Well, is that bacteria love iron? So will you
a Trojan horse approach where we will attach an antibiotic to iron, with the hope
that the bacteria will see that iron and eat it and suck it up and along with it, the antibiotic will go inside the cell and kill it, and we found that to be a pretty successful method so far for killing certain types of super bugs, and so you know
the stuff that I do is, as I mentioned before, kind of scary stuff, but I'm also really excited and optimistic about all
the amazing science. That's going on, where we're constantly trying to fool the bacteria and come up with the way to say
you know millions of lives. It's it's extraordinary, the kind of science that's being done, and I don't think we're talking about it enough. You know much of that work that you see in the newspapers has to do with the outbreaks or with the the evolution of these drug resistant bacteria. But I'd like to see a bit more about the the
profiles of the scientists who are coming up with new cures. Yeah I mean I can see the basis for hope, although we
a little slow in getting there. But you know it's the difference between not having a remedy
and having one that actually works and and works as emphatically as a antibiotic that works does in fact work. It's just amazing. The nineteen fifties must have been a a mind blowing decade to live through, to suddenly see the.
Is appalling diseases cured me. Well now we're talking about not just antibiotics, but I you know, let's add vaccines to that picture, and then it just begins to look like
every previous generation of humanity begins to look just unfortunate for having
born at the wrong time, because now we have these cures for diseases that people can just forget about for the rest of their lives. And yet the problem, as you point out in your book, is
We should have always known that the arms race would never stop these microorganisms are evolving quickly and, of course, our treatment
and you know in the worst case, are misuse of antibiotics is creating a selection pressure which will select for resist
absolutely yeah and- and you know, I open my book with a scene from the pre
antibiotic era, which is that we're-
on a battlefield in France, and there are these soldiers who are getting hit with shrapnel and they're getting infected,
and what do you do before their antibiotics? Well, you can try antiseptic fluid that didn't work. All that well or you can try
hacksaw and that increasingly is what people have to do is just go to the hacksaw and cut somebody's leg off to prevent them from getting an infection, and the reason for that
is that if the infection that's on the skin around the leg gets into the blood, that's called sepsis and if you have sepsis
you're going to die without antibiotics, and so you know I wanted to paint that picture for people to recognize that we're heading to a pre antibiotic era, where the drugs we've relied upon for seventy five years. Don't work anymore, and this is you know it's not up a period to
say it's not in a doomsday scenario, we have a chance to invest in new treatments, but we have to do so selectively and carefully, and this is really an inflection point for humanity. Where we can say this is an important issue. It's like global warming, it's like what
really. You know you hear about every day. This needs to be talked about in the same breath as a danger that we can invest in and come up with cures for what
talk about the problem of overuse, which is part of what God is here. I guess
know we would have gotten here. Even if we used these were these drugs as as Lee as possible, but there
is this pervasive problem of overuse and I'm wondering if the incentives are
misaligned here between the individual and society
eighty or, if or if, there's just a new way of understanding this, because when I think about what most people's experiences in getting sick are you,
watching their kid get sick and then facing the question of whether to treat with an antibiotic. It has been very frequent experience for many of
us to be prescribed an antibiotic essentially to be on the safe side,
empirically, you haven't even gotten to the point where an infection has been cultured and
you know, you know precisely what is responsive to your given
broad spectrum antibiotic- and this is just the Pru,
thing to do and now we're stepping back and saying? Well, this is not great for society because again we're part of the arms race that is creating a selection environment for super bug
But it's part of the problem here that what is in fact prudent for an individual is
raising the risk for society or the risks actually.
The same, and that is when it, when you are taking an antibiotic, as it said just to be on the safe side,
are you actually running the risk of breeding a super bug that is unlikely to be a problem for you? First or or is it conceivable that you are actually being prudent for yourself but conceivably becoming a problem for society and how you're younger using these drugs? Well, I'm a I'm a medical school professor at Cornell, and that question you just asked: is it what comes up on rounds almost every single day in various iterations, which is we got a patient in front of us who may have an infection,
and we're not sure do we give them an antibiotic just to be on the safe side, an generations of young doctors and old doctors have been dealing with that question. I'll tell you. I was giving a talk about superbugs couple of weeks ago and there was a guy who raised his hand and said you know how locusts were cast upon the earth as a judgment for human behavior. Do you think super bugs have been cast upon the earth as a similar judgment for human behavior
and the question caught me off guard at first, but there's an argument to be made that in the same way that we brought this on ourselves and in the issue really is
the small scale in the large scale on the small scale. We've got doctors who are prescribing antibiotics, as you mentioned, just to be on the safe side, and that's no longer good enough as an excuse to prescribe something and we've we've created a mechanism to check that we have these people in the hospital who are called antibiotics stewards and if you want to prescribe an antibiotic, an Ex one of our powerful drugs. The steward has to approve it and that's a job that I've
had before and I'll tell you it's a thankless job, because what happens is a surgeon? You know, orders an expensive antibiotic and then I have to call them and say: I'm sorry, that's the wrong drug and they say,
go come on please uh! This is I've been doing this twenty years. This is the drug. I use, and I have
They will not anymore. That's there's a better option for you and so we're trying to check that the doctors miss perspiring things, but also this is about patience, can do a better job as well. You know if your doctor prescribes five days of an antibiotic and you stop taking it after day too, because you're feeling better that gives the is the bugs a chance to mutate into a vault because you're not killing all of them, and so it selects out the
ones that can survive so that's sort of on the small scale, how we can be doing a better job? Let me, let me just ask you about the logic of that meant when the Stewart is no. No, no that don't use that drug use. This one is that case where here she is trying to preserve the efficacy of a
a yep, the last line defenses we have absolutely, and so what happens is I'll. Give you an example: there's an antibiotic called Mera Penam that we love
using because it is so strong and it wipes out just about everything, and so, if you're, a doctor who just performed- and you know, complicated, abdominal surgery, you want things to go well for that patient you're going to ask for me repair.
And I'm going to say well based on everything we know about the patient and the environment and the type of surgery you did. You could use ceftriaxone, which is not nearly as strong.
And then we have to have an argument about
to go forward- and you know I was listening to your your podcast with with Ricky Jervase, and he started out by telling you that there's no,
place for nuanced arguments anymore, and I felt so bad for him because all
I do is have nuanced arguments with people all day, long and
I have many nuanced arguments about antibiotics with very sharp surgeons and clinicians who really are advocating for their patient, and we have to be the ones as stewards to say. That's not the right drug and face
fallout if the antibiotic doesn't work. This is what I was worried about. So there really is
misalignment between the interests of the patient
you narrowly construed and the interest of society with respect to a choice about which drug to use absolutely- and you know this is I'm on the ethics Committee and my research interests sort of are the in
section of infectious diseases and medical ethics and what we talk about a lot and what I
study is: what do you do if you're a doctor- and you have a patient who's, got let's say two weeks to live, they've got terminal cancer and they get a super bug infection. Do you treat
them with one of the powerful antibiotics that we have one of our precious drugs in the arsenal and potentially breed resistance and potentially breed super bugs. But to save that patient, whose only got a few weeks to live as I've found, doctors approached
that question very differently and there's no uniform answer for them and so sort of the next generation of clinicians are sort of winging it and do figuring it out on the fly, which is how do you make life and death decisions when there is no formal training in how to do that, and so that's sort of on the small scale question of
antibiotics and then there's the larger scale issue, which is that we are using syphilis drugs and tuberculosis drugs in our orange groves. We're using are powerful
fungal drugs in tulip gardens were pumping meat
producing animals full of antibiotics- and you know when
for people here this they say: well, that's terrible! That should stop, but the reason that it doesn't stop is that there are powerful lobbies behind big orange. The meat industry. Big tulip is something
you have to contend with, and these are things that allow these groups allow the antibiotics to go in places they shouldn't and then, when we searched the soil around those tulips, it's full of
for bugs and if you're somebody with a weakened immune system you breathe in the
thing you could end up in the intensive care unit and we're trying to become much more judicious about how we use those drugs.
So how are oranges? Aren't tulips getting syphilis or they're going to a brothel there very promiscuous oranges and tulips, and we're trying to get you know starts with education, get get them early, but what we recognize that there have been just sort of this freewheeling approach to prescribing.
This is all over the world, and that brings up another issue, which is the more we look for super bugs the more we find them and people try to categorize. What's the burden of disease or what's the burden of these things around the
we don't even know what's going on in Africa or in many places in Sub Saharan Africa in Bangladesh and India. Every time we start looking for super bugs, we we end up
finding much more than we expected, and I think that that's only going to continue to grow in the years ahead. And so you know, part of it is, is getting better diagnostics. So then we can know what we're dealing with so that we can come up with treatment plants as far as the source of each new antibiotic. What
percentage of them come from nature. Maybe penicillin was a compound produced by a fungus right, so
how much of our drug development is a matter
find in happy accidents in nature and how much is is a US, synthesizing, yeah, new drugs based on a first principle, understanding of the target, microbe yeah, you you hit on the two major approaches switches. Do we just get lucky and and hope for the best, or do we build a new antibiotic
and both approaches have worked. What we're finding is that it's getting to be prohibitively expensive to build new antibiotics
Adam by atom or molecule by molecule, so what people
We're doing now is they're searching in the soil, and the reason for that is that you know beneath our feet. There is this: subterranean warfare, where survival of the fittest, bacteria and fungi are pumping out chemicals
to kill each other and if we can pull one of those out you've got yourself an antibiotic. The problem is that it typically
costs about a billion dollars and ten years of testing to show that that chemical is safe and effective as an antibiotic and fewer and fewer companies want to take that financial risk, because if they get that drug approved,
compare it to a blood pressure, medicine or a lipid lowering agent, these drugs antibiotics are prescribed. The the doctors very stingy about prescribing them. They're are only prescribed
short courses and then even that great new antibiotic is going to wear out its welcome. So these companies are saying no thank you.
We don't even want to go on a fishing expedition anymore, and so that has kind of led us to what I consider the most important medical issue that no one is talking about, which is that the antibiotic market is broken and we should be asking every politician every political candidate. What are you going to do to fix it? And so far we haven't heard anything and the the reason that this is a
Important is that many people are saying if the FED Fc Big Pharma doesn't want to make new drugs will good riddance. We should have the federal government do it. We should nationalize the production of antibiotics and that we should view these things as a a public good like electricity or water, and so we can say goodbye to big Pharma. That's a
risky proposition and one that I think you're gonna be hearing a lot more about in two thousand and twenty as more and more companies pull back from making these drugs just
reiterate a few things here. It is impressive how badly the market is able to incentivize what you just on its face is a civil
additional imperative. We clearly need to continue to develop
New antibiotics and yet
in the normal case. You know you and I may take one of these drugs once a decade.
And then, as you say, you know that very drug is probably
not gonna work very well. You know a couple of decades hens- and you know you compare this to something like you know- an anti depressant or a statin drugs that people take for the rest of their lives, in many cases every
hey from a business point of view it's night and day and well and people say you know the experts who I talk with at the at the FDA and people who are in drug discovery. They say we shouldn't look at antibiotics. The way we do an antidepressant. We should look at an antibiotic like a fire extinguisher that it's something that just makes us all safe simply by existing. Simply by being on the shelf, you can go into a hospital and feel comfortable that you're going to have that treatment if necessary, and that we need to disentangle the profit current profit model from the prescribing practices, and so there's this push now to have a different model where it's like a netflix or a a subscription service where hospitals have to subscribe to various antibiotics
to ensure that they are paying for them in the event that they need them, and so you know behind the scenes. There are all of these different proposals that are being put forth that are being hashed out in meetings around the world. You know whether or not we should do these things called push and pull incentives. A push incentive is to go to a pharmaceutical company sage.
Johnson and Johnson and say you guys have been really good at making antibiotics for a long time, and we see that you're losing interest. Why don't we cut your corporate tax rate from twenty percent to fifteen percent? If you, if you promise to invest a portion of those profits in new antibiotics
It's a surefire way to pump more money into the system. The problem is: this is the same Johnson and
Johnson. That's on trial in Oklahoma, for the causing the opioid epidemic, and so the
may not be the public will to go to AA a multi one billion dollars, big Pharma company and say hey. Could we give you guys a tax break so that you can keep making these drugs that keep us all alive? And then the other type of incentive is called a pull incentive which
to say to a company. If you take that billion dollar risk and you go through all of the clinical trials phase, one phase two phase three and you get it.
Drug approved, rather than giving you seven years of market exclusivity, but will give you twenty five years, so you can charge a higher rate for your antibiotics and this
You of market exclusivity is a really powerful one. I work with a company called Allegan that was just purchased, but what they did was they found this loophole, which is that if they transferred their patent for one of their I drugs to a native american reservation, the native Americans could invoke tribal sovereign immunity and no one could
challenge of the patent and they were going to split the profits, and so these kind of corporate shenanigans are happening behind the scenes. Most people, don't you know
aware of it, but those of us who are in
Development are often left scratching. Our heads saying is that league
is that okay of the these native Americans who've already been exploited for so long. We're we're now going to be manipulating them for for tax purposes and for generic competition. This doesn't seem right, it's just crazy that it seems like it should be. Straightforward to figure out a a solution here because obviously
we need to figure out how to incentivize this work, and I you know I I I understand how you know socializing at in the sense of you having government labs. Do the work that see you. You touch that your book, why that would not be optimal. The private sector is clearly
place where the most creative and sustainable approach to drug discovery his is occurring but figuring out how to subsidize this thing that it really it really just see it seems like people haven't
acquainted themselves with what the world will look like and will increasingly looks like in the absence of effective antibiotics
x rays, you just need a few of the other. Lady of your your book is is full of this information, but this is a place where you know that a sufficiently vivid and actor
is going to do more work than real data, because it is just. This should be an absolutely obvious priority. Well, I know is that the issue now is there's a lot of start ups that have looked
making antibiotics and they are pulling away because of the case. Study of a company called a cajun and a Cajun spent years and millions of dollars developing an antibiotic called, plays a Myson
and it finally got approved by the FDA in June of two thousand and eighteen, and it was approved to a lot of fan.
Fair and everyone was so excited, and the company filed for bankruptcy nine months later and the reason for that is that the drug got approved for urinary tract
actions, but no nobody needed that they wanted it for bloodstream infections and the company had bank yeah. They were betting, everything that they were gonna get the approval for bloodstream infections and they didn't and that sent the stock price plummeting and the company lost everything based on that, and so the smaller companies are saying. We can't afford to go into this anymore, because antibiotics is to have the highest failure rate of any type of new drug. That's in production, higher than chemotherapy drugs are blood, thinners or statins any of that stuff, and so it's becoming so expensive to pull these trials off and so did
well that increasingly people are saying screw it. Let's have the federal government take it over and then you have all these free market people who are saying? Oh, no, please don't have the federal government get more involved
my health care. That's a disaster waiting to happen. So you know this is. As I said, this is gonna, be the most important political issue that nobody's talking about Yet- and my hope is that from reading my book that when people hear a politician put forward a proposal to address this, that you'll be able to sniff out, is that a good proposal or is that a bad propose?
well. Does this politician have any idea what they're talking about or are they just you know reinventing the wheel or going down a road that is really going to prove to be a calamity and a huge waste of all of our taxpayer money, and so I think that you know the first step is just public. Engagement is just to recognize here's an issue. We can fix this if we all you know pitch in and how should we do that moving forward? It just seems to me that a certain class of medicines should be thought of as a almost like a utility.
Like like electricity. I think you actually, you might say this at some point in your book and you know if we were suffering power outages routinely and you know people were dying as a result. You know we would figure out some way to solve this problem. Is that it's a little bit like
we're talking about twenty thousand people worldwide. Now who are dying because of super bugs, that's the number isn't high enough to get people's attention if that goes to two hundred thousand people or beyond. Is this a situation when you think that it it has to get worse before we prioritize this yeah?
It's a good. The power outages, a sensitive subject for me because I'm in new york- and we had a big right- yes, had one large scale power outage over the weekend for five hours in our mayor with
in painting in Iowa and was nowhere to be found, and I I I think that that's a an apt comparison that you know the question is how bad does it have to get before people care? And you know I go around the country talking about this issue and every place. I go. People talk with me afterwards and tell me about a family member or a friend who
add a super bug infection and how there was no treatment available and then not only did they have to deal with the devastation of a family member contracting one of these things, but then they had to deal with questions surrounding contagions an you know: are they safe to go home? Are they going to be allowed to? Have visitors can be infected person? Have their grandchild come to the hospital to see them, and these are things that as clinicians we have to do such a better job explaining to people.
What what's good and what's not good, what's allowed? What's not allowed and there's so much fringe medicine out there and there's so many. You know Charlotte turns out there who are pitching. You know quick fixes that I think that the it's really challenging for people to navigate
get this stuff without without a good doctor that they can trust- and you know I've written about the fact that infectious disease, the specialty,
is having trouble recruiting new members. You would think that, with all of the interest in infectious diseases and how
superbugs are expanding around the world that you know pre med students would want to go into this field, but we're having trouble filling the training spots, and the reason is that, in fact,
disease doctors work harder than just about any other doctor in the hospital and they're paid less than just about everyone else and that's another, you know a financial issue that we must confront in the
is a head this another market failure, because a new infectious disease doctor doesn't get compensated for lots of paid procedures because there's not that many paid procedures beyond blood tests. I would imagine in that field. That's right! You know infectious disease is what we call a cognitive specialty
they give expert consultation, an expert advice they're not in there you know doing a cardiac, catheterization or they're, not cutting out a tumor and as such they just simply get paid less than
Anyone listening right now? If you know a doctor, ask them? What do you think of an infectious disease doctor and they'll probably say something like they're, the most thorough clinicians in the hospital or they're, the most thoughtful clinicians who are? Are there? You know the latest, the one the last ones to leave in the first ones to arrive, and it's it's
really been difficult for me to watch this field dwindle, and one of the messages I have is that it's such a wonderful field. You know we get to go in and and cure people, and it's one of these exciting fields that keeps getting bigger since I've become an infectious disease specialist. You know there have been so many new diseases that we found
when you're cardiologists. You know the number of heart problems that you're going to encounter is fairly stable, but with infectious diseases we keep finding new
is new fungi new parasites. So I've really got to stay on
top of my game just to provide basic care to my patients and trying to recruit the next generation
People is proving more and more difficult. Ah, I was really surprised in your
book to learn that the genomic sequencing of bacteria hasn't really helped drug discovery and in fact, at one point you say that this actually set back drug discovery for a generation
That's right! Well, you know one of the in the process of writing this book. I I sent it out to dozens of thought, leaders and scientists and doctors to get comma
it and they were all very positive. Except for one who told me he
really Craig Venter really did not like the book.
And- and I really I was kind of stung by that at first and then it turns out that he was the one who led the charge for that genomic sequencing project that I talk about. That was the you know the biggest blunder in scientific discovery for the last twenty five thirty years, and the idea was that if you could see Quinn
the entire genome of a bacterium. You could then home in on various targets, for antibiotics, and that just proved to be a big waste of money and we are we're still trying to recover from that. You know all of these big Pharma companies, Merc and Johnson and Johnson and AL organ. They became far more conservative. You know,
terms of the projects that they took on because they lost so much money in this you know wild goose chase, and so
We are now trying to convince them that pharmacy. You know that antibiotics can actually be profitable and and good for patients yeah, but they don't really care about that part. You know, I quote. One of the pharmaceutical ceos in my book said the,
he has an ethical mandate to charge as much money as possible for antibiotics, because he is fundamentally accountable to shareholders and not to patients.
And so whenever I go into a meeting with a pharmaceutical company, I remind myself that you know they're not
on the patient side, they're on the profit side and we have to figure
way to work with them to try to benefit the patients that I'm know
seeing every morning in the emergency room, one sidebar question: here's are bacteria becoming resistant to alcohol or any other chemical
we used to just like clean up in a search on instruments that aren't aren't big area of investigation is, what's the best hand sanitizer to use. We had to use alcohol based sanitizers for awhile, and now it's really pathogen specific. So, for example, if somebody has see death, which is the cluster team Dificil, we will not use alcohol based. We would just use soap and water because that's a better sanitizer, if you don't have see, definitely got one of the a typical run of the mill infection with. So you have the new macaca snow Monia. We could use Alka
based so it really depends patient to patient and that's kind of the you know. The future of personalized medicine is not only tailoring the treatments to patients, but then also the the contact precautions that we must take to prevent. Spreading of of these conditions is alcohol's just so good at killing microorganisms that there's really not a prospect that that what will
wake up one day and discover that it doesn't work. Neither and I'm not worried about us losing alcohol or bleach as really good disinfectants. You know every once in a while an organism pops up, that's resistant, but alcohol has not been a problem for us. It's not a problem for me personally. He put
enough for for that wrong mode of dispensation. That's right! I want to talk about some ethical issues here and the future. Just what's on the horizon here, but before we do that
since we started down this path. Maybe you can
little bit about anything?
you do personally that may be different from what the uninformed person
Does images or anything you do or don't do
Peter don't eat that people,
I wouldn't know yeah do or two yeah. I think, will question I get a lot is. Am I at risk for super bug infection and what I tell people is that I
go into the hospital every morning and I treat roughly five or six people who have super bug in FEB
actions and when I go home at night, I'm not worried that I'm going to be transmitting one of these infections. To my two young kids- and that's because I take you, know the prop
precautions, but also because I know that I have an intact immune system, and so one of the most important things people can do is just to have a basic conversation with your doctor and say how's. My immune system, so many of my patients, don't realize that they have a medical condition that slightly alters their immune system or that they're taking a medication that may predispose them to infect
and if you don't have one of those problems, you don't have to go around being worried that you're going to stumble upon a super bug infection. You know many of the patients. I see end up
having chemotherapy or they're on high dose steroids. They do they're on something that predisposes them. So I don't do
anything out of the ordinary, and I tried to to avoid.
I'd um, let's say going into a moldy basement, for example, because I know that that could be high risk. But you know I go swimming in the ocean. I go hiking
I'll go do sort of normal life stuff. I shake hands with people, nothing. You know, I don't have a weird diet:
although I'll say that I'm one of the people who, at the deli periodically my my order, gets rejected by the guy making the food, because it's so bizarre
I maybe I do need some unusual things why? What
yeah? I was the kind of guy who gets no cinnamon raisin,
bagel with eggs and hot sauce and
these and garlic and just they'll say what are you doing
so you're mentally ill. That's that's what you're saying yeah! You know it, you touched upon the ethical issue with these in infectious diseases and one of the challenges that we're having right now is with the reporting of this. In the example that I use is there is this fungal infection called Candida or us that we've been talking about in fungal circles for years, and it was put on the front page of the New York Times in April of this year.
And drew a lot of attention because there's no treatment for it, not like half the people who get it die, and I was quoted in that article and the day after that came out. I was in
bye, bye good Morning, America to go on and talk about this infection in my hospital pr staff said that they did not want me to do that, and I thought that was a an interesting, your decision, but they were concerned that it would draw attention to the fact that we have had
super bugs in our hospital and I ended up writing an op ed in the New York Times about this, saying that I think that hospitals are losing an important pr battle, that we should be open about what we're seeing and that we, the irony, is that the best hospitals in the country tend to see more super bugs right. As we've got the the most powerful diagnostics we got. The expert
We've got the best antibiotics we take on cases that are referred in from outside hospitals, so we shouldn't be ashamed or bed
that, we might have more super bugs, in fact, the candidate worst cases that I saw. I cured those people which I shouldn't you know we we should. We need to be able to spread the word about about how we're doing that and the ethics of talking about super bugs is something we still haven't figured out, and I think that that's something that we are going,
be wrestling with for the next generation. We don't want to freak people out. We don't want them to avoid medical care because they think they're going to walk into a hospital and get a super bug infection, and so what I'm pushing for is for experts to come out and say here's how we keep people
safe here's how we're trying to develop new cures. Here's what we can do to give people the best possible medical care, but that's easier, said than done
so far, and now I'm dimly remembering this story was this story where, in order to get this candida auris infection out of the room after
the patient died. They basically had to remove the the wall
you nailed it. That's exactly that's the one, my god yeah, that was terrifying. I could understand
what to write a hospital, not that one another, and you know you know we have experts who spent years studying this who've been saying. We need new, anti fungal treatments, and that was to me an opportunity to go out and and say we need to start thinking about this issue and there was this ostrich effect where they said. We don't want people to think about this issue, and so it's it's a challenge to convey this, and I think that we're
working on on the ways to do that appropriately. Yeah, there's just a there's, a a larger problem here with how to even think about the information one gets more. Transparency would seem to
an objective good here, and you know, as a consumer of medicine, you want to know you know which hospitals are
better than others and if you're, if you have to have a risky procedure, you'd want to know the mortality rates yet one hospital versus another. But it's hard to even think about the information one would get in that case because of the the best hospitals often take the hardest cases. So you're talking about it, you know more tell
the race, with respect to surgeries, what the trickiest surgeries air going to the best hospitals also writes. Absolutely it's like looking at a surgeon's success rate. Well, if they're only cherry picking the easiest cases that doesn't really tell you anything if your case is complicated, yeah, and so we ah, we don't think that just having full transparency is gonna help patients as consumers or as navigators of the health care system. So if we are going to release the names and amounts of superbugs that we're finding, we need to couple that with some sort of education. Otherwise, it's gonna look
like the terms and conditions for your Iphone just this big long list of of nonsense and that's not gonna help, anyone we'll see a lot, let's talk a little bit about them informed consent and how one goes about getting new drugs studied and and approved in your book, you run through the the litany of horror stories from the not too distant past, where it notions of informed consent were nonexistence enemy, talk about the doctors and the Tuskegee experiments in the US and when the details,
of these cases are as appalling as anyone who's familiar with them can dimly. Remember a mistress. It's really hard to understand that these were doctors involved in these cases. But this is the you know. That's the kind
text from which we are emerging,
and now we have protocols in place to be a scrupulous as possible, ethically with respect to enrolling people into studies and testing drugs on on human sub.
Are we as good as as you can imagine us being at this point, or are you finding that,
still run into ethical, quandaries and practices that seem to comp.
My you or anyone else who's doing this work right. Well,
that's the thing is when I'm not treating patients, I'm experimenting on them and that's something that I take very seriously. But my job is to bring in new
drugs that have never been used in our hospital before and I go up to patients- and I say you want to try this and to get a drug approved for a clinical trial at my hospital- is incredibly difficult. Typically takes almost a year of going back and forth with something called an institutional review board an I r b and they can make your life miserable because they want every single issue ironed out before you get to waltz into the hospital with some experimental treatment- and you know I wrote about the history,
of human experimentation, to explain why we have the protocols and the oversight in place that we do now and what you hit upon is what's so jaw dropping about this, which is that physicians were doing horrible things to patients. You know decade after decade and they were largely left to police themselves, and you know I talked about the Tuskegee experiment,
dinosaur that the Nazi doctors- and you know they were looking at each other saying yeah. This is okay, but I think this is fine, and that was it it's just outrageous looking through the lens of history, but it has created a number of safeguards that
protect patients, and you know what I wanted people to do. If they read my book is to say you know, if the doctor comes up to them and says
do you want to be in a clinical trial? You can have some idea of what that might entail, and one of the ethical challenges I have is that sometimes patients will consent to a trial
or to take an experimental drug and I'm not always sure that they know
what they're getting themselves into that. They will give me consent, but I don't know if it's informed consent and that
the really fine line to be on you know it's like a high wire act. When you don't want to exploit somebody, but if they've got let's say an eighth grade, education and you're talking to them about superbugs, an novel treatments, Ann you're, trying to
you make the information accessible to them without dumbing. It down. That's a that's, a very powerful position to be in, and it's one that I think we all take very seriously, and it's a good thing that we have these safeguards in place so that you know a guy like me, can't just walk
to the hospital and say hey. I saw this new treatment on the group website and I think it would be great for all the patients. Let's, let's give it a shot. There are
a number of people who will stop me and say what do you think you're doing, and I think that's a really important point when you read about-
clinical trials to know that there are a lot of people making sure that patients best interests are at heart so
and now we, whatever I slender rays of hope, can be brought into the converse
and this is where they will appear, what is
on the horizon and what are the prospects of solving this problem, and I think that we have a lot of reason to be hopeful. Some of
brightest minds. You know I was mentioning that a lot of doctors don't want to be infectious disease specialists, but a lot of the brightest minds in basic science are interested in tackling this problem and are interested in discovering new by
Fedex, and so the real issue here is that we are going to find new chemicals and new molecules that can be used to cure people. We just have to figure out who's going to pay for it, because whenever we find one of these chemicals they have to go through testing in a test tube
and then in animals, and then in healthy human volunteers and then in patients who have that being a super bug infection and that whole process is, you know, really expensive and we just have to figure out. Is this going to be led by big pharma, or is this going to be led by the federal government? That's an issue that, ultimately we are going to have to figure out and then we're going to reconcile these financial issues. We just have to start asking our leaders how
we're going to do it. So I'm very optimistic that we're going to fix this. What about the role for deep pocketed philanthropy
s? So you know in the bill and Melinda Gates Foundation and in England there is the Wellcome Trust and there are a lot of deep pockets who are funding stuff over there.
The problem we have is, you know, super bugs have in some ways been compared to the AIDS epidemic and when H I
he came on the scene in the early nineteen eighties. The difference is when that happened. There was this huge public push to find a cure and the more you know think back to all of the gallows and the the celebrities who got behind this issue and raised. You know billions of dollars and we immediately came up with trees,
mints that save lives. We're not seeing this with super bugs, for whatever reason we have a branding problem, which is that we have not. I can't think of a single influence
or celebrity or thought leader or whatever you want to call them who actually wants to make this their issue. There's this vacuum because it
going. As you know I mentioned earlier, this is going to be the biggest killer in the world. You know by two thousand and fifty and somebody needs to take the mantle and say we need to come up with ah way to go
up with cures. Let's do this now, rather than waiting until it's too late, so we're going to figure it out, it's just a matter of who's, going to be on fund it, and I hope that we'll we'll sort that
how soon. Well I I know that I have at least a few billionaires to listen to this podcast so good. If you're out there get this message, because it's ridiculous, but that it is a kind of pr problem. You need a clear enough case where this becomes insane that we have. We have not prioritize this and we take stock of our madness and
immediately marshal our resource is, you know- and I see these cases every single day and they're the people that I wrote about in my book, but you're right. It hasn't been a high profile enough case for people toe, have the fun
raising and and for the money to pour in to address this issue. But you know doctors are seeing this every day. Patients are are dealing with that families, it's devastating it's it's, and it's only expanding this problem is, is not something that's going to go away. If we just you know, stick our head
in this, and we got to do something. Now: it's not going to go away and on some level
never go away unless we find some evolution. Canceling logic by which we we address the problem right. So this is a you know it it's a little bit like we have the earth crossing asteroids problem, but it
you know, they're actually landing with some regularity, and we see more coming and there's just no question that they're going to hit. So we need to figure out the mechanism of deflection. That's right! That's right- and you know every once in awhile, a super bug gets attention the way,
ended. Oris was on the front page of the times, and you know that led one of our senators chuck Schumer to come out and say that
the federal emergency and that we need to tackle this. But I don't like that. That's a very passive way of dealing with the problem of waiting. Until you know, a prominent newspaper takes this issue on one ways to be more proactive than to learning, to learn about it and then to engage with the issue and ask you know that our our politicians and the people who fund philanthropy to say let's do something about this and and move the ball forward, because there are a lot of scientists and doctors who are eager for the research support took to keep pushing this forward
Are there any foundations at this moment that people could support the fun this work, uh the bill and Melinda Gates Foundation and the Wellcome Trust have done a lot of work so far, but one of the problems we have is that we've had this partnership for seventy five years, where the federal government funds basic scientists to discover these molecules and then they partner with Big Pharma, to go through the approval process, and we see that that partnership is dissolving, and so I think that one of the challenges we have right now is
figuring out who's going to take up that partnership and what is going to be the mechanism for let's say that Nobel Prize Winning Scientist, who discovers a new treatment for MRSA, who are they going to partner with to bring that drug to the market and we're still trying
figure out? Who that's going to be. But right now, I would say, invest
the NIH investing in welcome trusted. These are, are really good places to start what. Why is that? Partnership is often well. It's come back to the the dollars and cents. The London school of Economics did a study and said that if a if a big pharmaceutical company invests in a new antibiotic, the net present value is negative. Fifty million dollars they can expect to lose that much money
right, and so the companies are saying you know we're gonna do something else with our time, and this is a lot of the companies I work with- are trying to bundle their anti infective as units and sell them off because they're,
they're losing the money, and it's a it's just a something, that's very hard to explain to a patient who is dying of a super bug, infection that there is no treatment, because the pharmaceutical industry lost interest in in coming up with a cure yeah. It's almost like there could be some creative way to bundle this with what you know by comparison as an obvious miss
appropriation of our fundamental, for instance. I would we spend, I don't know how many billion dollars a year on cosmetics right and is it something it's got to be, something
you know forty billion dollar a year industry. Why not actually just add a attacks to a certain class of product that would go directly to solve this problem and like if you
for every every thirty dollar, lipstick or whatever. I don't know what it costs, but you doesn't.
Can you add, zero dollars and fifty cents that would go to deal with this problem at that? Would that we we have already established the market is not good at incentivizing, but it seems like that. You,
a campaign of supporter. Well, it's such a great idea. I mean you know. I mentioned the company AL organ that makes a new antibiotic called double Vance and they also make botox
they had three billion dollars in sales last year and Botox, which was the only
reason they had the resources to invest in antibiotics in the first place. So I love this idea of coupling ah cosmetic tax with a drug discovery, antibiotic incentive, so
you may be on to something there. I guess that many it well in that case wouldn't be attacks. It could just be the cosmetic companies themselves could use it as a pr campaign. You know they could you know it's like they're there, red campaign or whatever yeah
all right if you, if you are a running, a cosmetics company, you can take this idea for free and I will buy your lipstick what
price point: so there was actually there
one thing you wrote about in your book, which I don't recall if the other shoe ever finally dropped on. But you
You wrote about a a license based treatment for infections. How has that evolved? That was one of the exciting parts of doing research, for this book was trying to find all of the new treatments that are in clinical development and one is this thing called license which can cause bacteria to explode, and it was discovered by this guy Vince Fischetti at Rockefeller University, and you know I talk about how he's been working on this for forty plus years and it's only finally in clinical trials now, and the reason is that the companies didn't think it would be profitable. And here you have this brilliant scientists sitting on and a life changing discovery, and it wasn't going anywhere simply because of the the financial incentives. But there was just data released two months ago at one of the major infectious disease conferences that this license there
he is very promising for treating Mercer. The challenge you with any of these new treatments is that the big companies want broad spectrum treatments, and so, when you ever you hear that there is a new cure for a specific pathogen, whether it's Lyme disease or mercy or candid or us or whatever
The problem is, those are very narrow spectrum, and that means that they're not gonna make as much money off of them. They want a drug that can cure all types of bacterial infections, and so the challenge with license is going to be that it's very expensive to produce and it can only cure certain types of infections, and so we've got to figure out a method. This is the same thing like with the back to the the phase therapy bacteriophage therapy. We can use these genetically engineered viruses that can make bacteria explode, and this was just done in May, with a fifteen year old girl from England who had a mycobacterium obsesses infection that wouldn't go away and they used,
cocktail of three bacteria phases toe treat her. It was. This extraordinary story is on the cover of ah the Wall Street Journal on all over the place and soon, as I read it, I said well, they're never going to make this accessible toe patients it's just too expensive and that infection is too rare,
and so what we're doing is comparing it to other orphan diseases. You know things like mitochondrial diseases or certain diseases that the companies will never turn a profit on and figuring. How do we incentivize them to keep developing these things when they're so narrow spectrum and the profit
margins are so slim and- and you know it's unfortunate- how many of these big decisions come down to dollars and cents? It's amazing that this entire problem is sub.
Um and produced by a a massive market failure- and is- it was just a place where we just have to relinquish our free market fundamentalism. I mean that those of us who are convinced that the private sector should do everything that the private sector does best. Well, yes, the the the you know that that's still true, but this is clearly a point of critical
failure. You can understand it in the case of a disease that is so rare that you know the normal person is unlikely.
To meet anyone who's ever met anyone who's had it right where it's just your. If something effects sufficiently tiny
people will. Then you know it's it's understandable how you that no one was
spend a billion dollars to solve that particular problem, but we're talking about something that's going to affect
everyone. Eventually, if you know our most basic antibiotics
they'll absolutely. You know I was a biophysics major as an undergrad, and I didn't take any economics courses and it's only after I became a doctor that I had to get a crash course in economics.
To understand terms like market failure, and you know understanding what push and pull incentives are, and so much of the work that I do now is trying to figure out. How do we bring an expensive new treatment into a hospital and convince the hospital that they can pay for it and that you know it's? It's not just about Ben
Bing patients. So much of the in Superbugs issue is that we need better diagnostic tests and companies will appear
Watch me and say: hey we've got this great new diagnostic test and I'll say are house
well was never going to be able to pay for it, and that's such a shame that we are at this point where we're not thinking first about how we can benefit patients with better tests and better treatments were first thinking. How are we going to pay for it and again it comes
Back to this issue of being a market failure, supply and demand curves no longer work when you're talking about individual patients who are
vulnerable and who are dying and we've got to do something different, and I think that you know public engagement is the first step understanding the issued so that we can tackle it.
Well again. Your book is a great read, it's super bugs and
and dumb. I really thank you for taking the time to come on the podcast MAC, because it's just it's great to finally tackle this issue. Thanks.
For having me, this was great. If you find this podcast valuable, there are many ways you can sit
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Transcript generated on 2019-09-15.