TEDMED 2014
Ramanan Laxminarayan: The coming crisis in antibiotics
Ramanan Laxminarayan: Nadolazeća kriza s antibioticima
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Antibiotici spašavaju živote. Ali ih jednostavno previše koristimo, često i u svrhe nenamijenjene spašavanju života, kao što je liječenje gripe ili uzgoj jeftinijih pilića. Istraživač Ramanan Laxminarayan tvrdi kako je rezultat toga prestanak djelovanja tih lijekova na sve ljude, jer bakterije koje napadaju postaju sve više otporne. Poziva nas sve, i pacijente i liječnike podjednako, da razmislimo o antibioticima i njihovoj trenutačnoj učinkovitosti kao o ograničenom resursu te da dvaput razmislimo prije nego li ih upotrijebimo. Otrežnjujući pogled na to kako globalni medicinski trendovi mogu imati značajni negativan učinak.
Ramanan Laxminarayan - Drug-resistance economist
At the Center for Disease Dynamics, Economics & Policy, economist Ramanan Laxminarayan looks at big-picture issues of global health. Full bio
At the Center for Disease Dynamics, Economics & Policy, economist Ramanan Laxminarayan looks at big-picture issues of global health. Full bio
Double-click the English transcript below to play the video.
00:12
The first patient to ever be
treated with an antibiotic
treated with an antibiotic
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Prvi pacijent liječen antibioticima
00:16
was a policeman in Oxford.
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bio je policajac u Oxfordu.
00:17
On his day off from work,
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Na njegov slobodan dan,
00:19
he was scratched by a rose thorn
while working in the garden.
while working in the garden.
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ogrebao se o trn ruže radeći u vrtu.
00:23
That small scratch became infected.
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Ta je mala ogrebotina postala inficirana.
00:26
Over the next few days,
his head was swollen
his head was swollen
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Tijekom sljedećih dana,
glava mu je natekla
glava mu je natekla
00:29
with abscesses,
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od gnojnih čireva
00:30
and in fact his eye was so infected
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i oko mu je bilo toliko inficirano
00:33
that they had to take it out,
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da su mu ga morali izvaditi.
00:35
and by February of 1941,
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Do kraja veljače 1941. godine,
00:38
this poor man was on the verge of dying.
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ovaj je jadni čovjek bio na rubu smrti.
00:40
He was at Radcliffe Infirmary in Oxford,
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Nalazio se u Radcliffe ambulanti u Oxfordu
00:43
and fortunately for him,
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i, na njegovu sreću,
00:45
a small team of doctors
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mali tim liječnika
00:47
led by a Dr. Howard Florey
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predvođen doktorom Howardom Floreyem
00:48
had managed to synthesize
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uspio je sintetizirati
00:50
a very small amount of penicillin,
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veoma malu količinu penicilina,
00:53
a drug that had been discovered
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lijeka kojeg je otkrio
00:55
12 years before by Alexander Fleming
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Alexander Fleming 12 godina prije,
00:58
but had never actually been
used to treat a human,
used to treat a human,
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ali nikada nije primijenjen na čovjeka
01:01
and indeed no one even
knew if the drug would work,
knew if the drug would work,
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i nitko nije znao hoće li lijek djelovati,
01:04
if it was full of impurities
that would kill the patient,
that would kill the patient,
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sadrži li nečistoće koje bi
mogle ubiti pacijenta,
mogle ubiti pacijenta,
01:07
but Florey and his team figured
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ali su Florey i njegov tim shvatili
01:09
if they had to use it,
they might as well use it
they might as well use it
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da ako već moraju,
mogli bi ga upotrijebiti
mogli bi ga upotrijebiti
01:11
on someone who was going to die anyway.
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na nekome tko će svakako umrijeti.
01:14
So they gave Albert Alexander,
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Tako su Albertu Alexanderu,
01:17
this Oxford policeman, the drug,
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oxfordskom policajcu, dali lijek
01:20
and within 24 hours,
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i unutar 24 sata,
01:23
he started getting better.
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počeo se oporavljati.
01:25
His fever went down,
his appetite came back.
his appetite came back.
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Spustila mu se temperatura,
vratio mu se apetit.
vratio mu se apetit.
01:29
Second day, he was doing much better.
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Drugog mu je dana bilo puno bolje.
01:31
They were starting to
run out of penicillin,
run out of penicillin,
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Počelo im je nedostajati penicilina
01:33
so what they would do
was run with his urine
was run with his urine
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pa bi trčali s njegovim urinom
01:35
across the road to re-synthesize
the penicillin from his urine
the penicillin from his urine
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preko ceste, kako bi resintetizirali
penicilin iz njegova urina
penicilin iz njegova urina
01:38
and give it back to him,
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i ponovno mu ga dali,
01:40
and that worked.
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i to je uspijevalo.
01:42
Day four, well on the way to recovery.
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Četvrti je dan bio
na dobrom putu oporavka.
na dobrom putu oporavka.
01:44
This was a miracle.
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To je bilo čudo.
01:46
Day five, they ran out of penicillin,
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Peti dan su ostali bez penicilina
01:50
and the poor man died.
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i siroti je čovjek preminuo.
01:52
So that story didn't end that well,
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Tako da ta priča nije završila baš lijepo,
01:55
but fortunately for
millions of other people,
millions of other people,
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ali, na sreću milijuna drugih ljudi,
01:59
like this child who was treated
again in the early 1940s,
again in the early 1940s,
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kao ovog djeteta liječenog
u ranim 1940-ima,
u ranim 1940-ima,
02:02
who was again dying of a sepsis,
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koje je umiralo od sepse
02:05
and within just six days, you can see,
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i koje se u samo šest dana,
kao što možete vidjeti,
kao što možete vidjeti,
02:08
recovered thanks to this
wonder drug, penicillin.
wonder drug, penicillin.
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oporavilo zahvaljujući ovom
čudesnom lijeku, penicilinu.
čudesnom lijeku, penicilinu.
02:12
Millions have lived,
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Milijuni su preživjeli
02:14
and global health has been transformed.
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i globalno zdravstvo se transformiralo.
02:17
Now, antibiotics have been used
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Antibiotici su se koristili
02:20
for patients like this,
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za pacijente poput ovih,
02:23
but they've also been
used rather frivolously
used rather frivolously
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ali korišteni su i veoma neozbiljno
02:25
in some instances,
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u nekim slučajevima,
02:27
for treating someone
with just a cold or the flu,
with just a cold or the flu,
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za liječenje samo prehlade ili gripe,
02:29
which they might not have
responded to an antibiotic,
responded to an antibiotic,
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koje ne bi reagirale na antibiotik.
02:32
and they've also been
used in large quantities
used in large quantities
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Također su korišteni u velikim količinama
02:36
sub-therapeutically, which
means in small concentrations,
means in small concentrations,
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ne-terapeutski, odnosno
u malim koncentracijama
u malim koncentracijama
02:39
to make chicken and hogs grow faster.
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za brži rast pilića i svinja.
02:42
Just to save a few pennies
on the price of meat,
on the price of meat,
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Samo kako bi smanjili cijenu mesa
za nekoliko penija,
za nekoliko penija,
02:46
we've spent a lot of
antibiotics on animals,
antibiotics on animals,
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potrošili smo mnogo antibiotika
na životinje,
na životinje,
02:49
not for treatment, not for sick animals,
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ne za liječenje, ne za bolesne životinje,
02:51
but primarily for growth promotion.
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već prvenstveno za potpomognut rast.
02:54
Now, what did that lead us to?
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Kamo nas je to dovelo sada?
02:57
Basically, the massive use of antibiotics
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U osnovi, masivna upotreba antibiotika
03:00
around the world
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diljem svijeta
03:01
has imposed such large
selection pressure on bacteria
selection pressure on bacteria
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nametnula je tako veliki
selektivni pritisak na bakterije
selektivni pritisak na bakterije
03:05
that resistance is now a problem,
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da je sada otpornost postala problem
03:08
because we've now selected for just
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jer su opstale samo
03:10
the resistant bacteria.
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rezistentne bakterije.
03:11
And I'm sure you've all read
about this in the newspapers,
about this in the newspapers,
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Siguran sam da ste svi
čitali o ovome u novinama,
čitali o ovome u novinama,
03:14
you've seen this in every magazine
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da ste vidjeli ovo u svakom časopisu
03:16
that you come across,
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na koji ste naišli,
03:18
but I really want you to appreciate
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ali stvarno želim da u potpunosti shvatite
03:20
the significance of this problem.
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važnost ovog problema
03:22
This is serious.
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Ovo je ozbiljno.
03:23
The next slide I'm about to show you is
of carbapenem resistance in acinetobacter.
of carbapenem resistance in acinetobacter.
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Sljedeći dijapozitiv prikazuje otpornost
acinetobactera na karbapenem.
acinetobactera na karbapenem.
03:28
Acinetobacter is a nasty hospital bug,
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Acinetobacter je gadna bolnička bakterija,
03:31
and carbapenem is pretty much
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i karbapenem je poprilično
03:32
the strongest class of antibiotics
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najjača vrsta antibiotika
03:34
that we can throw at this bug.
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kojom možemo napasti ovu bakteriju.
03:36
And you can see in 1999
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Možete vidjeti da je u 1999.
03:39
this is the pattern of resistance,
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ovo bio uzorak otpornosti.
03:42
mostly under about 10 percent
across the United States.
across the United States.
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većinom ispod 10 posto
širom Sjedinjenih Država.
širom Sjedinjenih Država.
03:45
Now watch what happens
when we play the video.
when we play the video.
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Sada pogledajte što se događa
kada pokrenemo video.
kada pokrenemo video.
03:58
So I don't know where you live,
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Ne znam gdje živite,
04:00
but wherever it is, it certainly is a lot worse now
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ali gdjegod to bilo,
zasigurno je puno gore sada
zasigurno je puno gore sada
04:03
than it was in 1999,
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nego što je bilo 1999. godine.
04:05
and that is the problem of antibiotic resistance.
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To je problem s otpornošću na antibiotike.
04:09
It's a global issue
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Ovo je globalno pitanje
04:11
affecting both rich and poor countries,
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koji jednako pogađa
i bogate i siromašne zemlje,
i bogate i siromašne zemlje,
04:14
and at the heart of it,
you might say, well,
you might say, well,
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i u njegovoj srži,
mogli biste pitati
mogli biste pitati
04:16
isn't this really just a medical issue?
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nije li to zapravo samo medicinski problem?
04:18
If we taught doctors how not
to use antibiotics as much,
to use antibiotics as much,
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Ako bismo naučili doktore
ne koristiti antibiotike toliko,
ne koristiti antibiotike toliko,
04:20
if we taught patients how
not to demand antibiotics,
not to demand antibiotics,
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ako bismo naučili pacijente
ne zahtijevati antibiotike,
ne zahtijevati antibiotike,
04:23
perhaps this really wouldn't be an issue,
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možda ovo zapravo ne bi bio problem
04:25
and maybe the pharmaceutical companies
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i možda bi farmaceutske kompanije
04:27
should be working harder to develop
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trebale više raditi na razvoju
04:28
more antibiotics.
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više antibiotika.
04:30
Now, it turns out that there's something
fundamental about antibiotics
fundamental about antibiotics
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No, ispada da postoji nešto fundamentalno
u vezi s antibioticima
u vezi s antibioticima
04:33
which makes it different from other drugs,
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što ih razlikuje od drugih lijekova,
04:35
which is that if I misuse antibiotics
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a to je da ako ja
zloupotrijebim antibiotike
zloupotrijebim antibiotike
04:37
or I use antibiotics,
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ili ako koristim antibiotike,
04:39
not only am I affected but
others are affected as well,
others are affected as well,
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nisam samo ja pogođen,
već su i drugi ljudi pogođeni
već su i drugi ljudi pogođeni
04:43
in the same way as if I
choose to drive to work
choose to drive to work
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na isti način kao da odlučim
odvesti se na posao
odvesti se na posao
04:45
or take a plane to go somewhere,
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ili otići negdje avionom,
04:48
that the costs I impose on others
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troškovi koje nametnem drugima
04:50
through global climate change go everywhere,
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kroz globalne klimatske promjene
prisutni su svugdje
prisutni su svugdje
04:52
and I don't necessarily take
these costs into consideration.
these costs into consideration.
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i ja ne uzimam, nužno, te troškove u obzir.
04:55
This is what economists might
call a problem of the commons,
call a problem of the commons,
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Ovo je ono što bi ekonomisti
mogli nazvati problemom zajednice,
mogli nazvati problemom zajednice,
04:58
and the problem of the commons is exactly
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i problem zajednice je točno
05:00
what we face in the case
of antibiotics as well:
of antibiotics as well:
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ono s čim se suočavamo
i u slučaju antibiotika:
i u slučaju antibiotika:
05:02
that we don't consider —
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da ne uzimamo u obzir —
05:04
and we, including individuals, patients,
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i mi, uključujući pojedince, pacijente,
05:07
hospitals, entire health systems —
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bolnice, čitav zdravstveni sustav —
05:11
do not consider the costs
that they impose on others
that they impose on others
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ne uzimamo u obzir troškove
koje oni nameću drugima
koje oni nameću drugima
05:13
by the way antibiotics are actually used.
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načinom na koji su antibiotici
zapravo korišteni.
zapravo korišteni.
05:15
Now, that's a problem that's similar
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Ovaj je problem sličan
05:17
to another area that we all know about,
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drugome području za koje svi znamo,
05:19
which is of fuel use and energy,
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a to je upotreba goriva i energije,
05:21
and of course energy use
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i naravno, upotreba energije
05:23
both depletes energy as well as
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i iscrpljuje energiju kao što i
05:26
leads to local pollution
and climate change.
and climate change.
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vodi do lokalnog zagađenja
i klimatskih promjena.
i klimatskih promjena.
05:29
And typically, in the case of energy,
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I tipično, u slučaju energije,
05:31
there are two ways in which
you can deal with the problem.
you can deal with the problem.
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postoje dva načina na koja se može
nositi s problemom.
nositi s problemom.
05:33
One is, we can make better
use of the oil that we have,
use of the oil that we have,
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Jedan je da bolje koristimo
naftu koju imamo,
naftu koju imamo,
05:37
and that's analogous to making better use
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što je analogno boljoj upotrebi
05:39
of existing antibiotics,
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postojećih antibiotika,
05:41
and we can do this in a number of ways
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a to možemo učiniti na brojne načine
05:42
that we'll talk about in a second,
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o kojima ćemo pričati ubrzo,
05:45
but the other option is the
"drill, baby, drill" option,
"drill, baby, drill" option,
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dok je druga opcija poticanje traženja
novih naftnih bušotina,
novih naftnih bušotina,
05:48
which in the case of antibiotics
is to go find new antibiotics.
is to go find new antibiotics.
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odnosno, u slučaju antibiotika,
traženje novih antibiotika.
traženje novih antibiotika.
05:53
Now, these are not separate.
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Ovo dva načina nisu odvojena.
05:55
They're related, because if we invest heavily
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Povezani su, jer ako mnogo ulažemo
05:58
in new oil wells,
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u nove naftne bušotine,
06:00
we reduce the incentives
for conservation of oil
for conservation of oil
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smanjujemo poticaje za očuvanje nafte
06:03
in the same way that's going
to happen for antibiotics.
to happen for antibiotics.
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i to će se na isti način
dogoditi s antibioticima.
dogoditi s antibioticima.
06:06
The reverse is also going
to happen, which is that
to happen, which is that
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Događa se i obrnuto,
06:08
if we use our antibiotics appropriately,
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ako prigodno koristimo naše antibiotike,
06:10
we don't necessarily have
to make the investments
to make the investments
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ne moramo nužno ulagati
06:13
in new drug development.
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u razvoj novih lijekova.
06:15
And if you thought that these two were entirely,
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Ako ste mislili da je ovo dvoje u cjelosti,
potpuno balansirano
između ove dvije opcije,
između ove dvije opcije,
06:18
fully balanced between these two options,
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06:20
you might consider the fact that
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mogli bi razmotriti činjenicu da
06:22
this is really a game that we're playing.
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je ovo zapravo igra koju igramo.
06:24
The game is really one of coevolution,
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To je zapravo igra koevolucije,
06:27
and coevolution is, in
this particular picture,
this particular picture,
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a koevolucija je, na ovoj slici,
06:30
between cheetahs and gazelles.
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između geparda i gazela.
Gepardi su evoluirali
tako da trče brže,
tako da trče brže,
06:32
Cheetahs have evolved to run faster,
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06:34
because if they didn't run faster,
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jer da ne trče brže
06:35
they wouldn't get any lunch.
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ne bi imali što jesti za ručak.
06:37
Gazelles have evolved to run faster because
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Gazele su evoluirale da trče brže jer
06:40
if they don't run faster, they would be lunch.
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ako ne bi trčale brže,
one bi postale ručak.
one bi postale ručak.
06:43
Now, this is the game we're
playing against the bacteria,
playing against the bacteria,
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To je igra koju mi
igramo protiv bakterija,
igramo protiv bakterija,
samo što mi nismo gepardi,
06:46
except we're not the cheetahs,
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06:48
we're the gazelles,
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mi smo gazele,
06:49
and the bacteria would,
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i bakterija bi,
06:52
just in the course of this little talk,
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samo za vrijeme ovog kratkog govora,
06:54
would have had kids and grandkids
156
402549
1426
dobila djecu i unuke,
06:55
and figured out how to be resistant
157
403975
2385
i shvatila kako biti rezistentna
06:58
just by selection and trial and error,
158
406360
2474
samo putem selekcije
te probom i pogreškom,
te probom i pogreškom,
07:00
trying it over and over again.
159
408834
1912
pokušavajući neprestano iznova.
07:02
Whereas how do we stay
ahead of the bacteria?
ahead of the bacteria?
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3772
S obzirom na to, kako
ostati ispred bakterija?
ostati ispred bakterija?
07:06
We have drug discovery processes,
161
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2054
Imamo procese otkrivanja lijekova,
07:08
screening molecules,
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1630
provjeravanje molekula,
07:10
we have clinical trials,
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1728
imamo klinička ispitivanja,
07:11
and then, when we think we have a drug,
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2148
i onda kada mislimo da imamo lijek,
07:14
then we have the FDA regulatory process.
165
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3745
onda imamo regulatorni proces
Uprave za hranu i lijekove.
Uprave za hranu i lijekove.
07:17
And once we go through all of that,
166
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2178
Nakon što prođemo kroz to sve,
07:20
then we try to stay one step ahead
167
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2265
onda pokušavamo ostati korak ispred
07:22
of the bacteria.
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2296
bakterija.
07:24
Now, this is clearly not a
game that can be sustained,
game that can be sustained,
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2777
Jasno je da je ovo igra koja
ne može biti održana,
ne može biti održana,
ili koja se može pobijediti
07:27
or one that we can win
170
435339
1137
07:28
by simply innovating to stay ahead.
171
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1837
samo inovacijama kako biti u prednosti.
07:30
We've got to slow the pace of coevolution down,
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3305
Moramo usporiti tempo koevolucije,
07:33
and there are ideas that we
can borrow from energy
can borrow from energy
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3682
i postoje ideje koje možemo
posuditi od energije
posuditi od energije
07:37
that are helpful in thinking about
174
445300
1770
i koje su od pomoći kada razmišljamo
07:39
how we might want to do this in the case
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447070
1537
kako bi to mogli napraviti u slučaju
07:40
of antibiotics as well.
176
448607
1546
antibiotika, također.
07:42
Now, if you think about how we deal with
177
450153
2240
Ako razmislite kako se nosimo s
07:44
energy pricing, for instance,
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1423
cijenom energije, na primjer,
07:45
we consider emissions taxes,
179
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1849
uzimamo u obzir porez na emisije,
07:47
which means we're imposing
the costs of pollution
the costs of pollution
180
455665
2584
što znači da namećemo trošak zagađenja
07:50
on people who actually use that energy.
181
458249
2831
ljudima koji zapravo koriste tu energiju.
07:53
We might consider doing that for antibiotics as well,
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461080
2980
Mogli bi razmotriti da isto
učinimo s antibioticima,
učinimo s antibioticima,
07:56
and perhaps that would make sure that antibiotics
183
464060
2711
i možda bi to osiguralo da se antibiotici
07:58
actually get used appropriately.
184
466771
2401
zapravo umjesno koriste.
08:01
There are clean energy subsidies,
185
469172
2028
Postoje subvencije za čistu energiju,
08:03
which are to switch to fuels
which don't pollute as much
which don't pollute as much
186
471200
3055
koja koristi goriva koja ne zagađuju toliko
08:06
or perhaps don't need fossil fuels.
187
474255
2845
ili možda ne treba fosilna goriva.
08:09
Now, the analogy here is, perhaps we need
188
477100
2860
Analogija je slijedeća: možda se trebamo
08:11
to move away from using antibiotics,
189
479960
2260
udaljiti od upotrebe antibiotika,
08:14
and if you think about it, what are
good substitutes for antibiotics?
good substitutes for antibiotics?
190
482220
3716
i ako razmislite o tome, koje su
dobre zamjene za antibiotike?
dobre zamjene za antibiotike?
08:17
Well, turns out that anything that reduces
191
485936
2164
Izgleda da bi bilo što što smanjuje
08:20
the need for the antibiotic would really work,
192
488100
2243
potrebu za antibioticima
stvarno funkcioniralo,
stvarno funkcioniralo,
08:22
so that could include improving
hospital infection control
hospital infection control
193
490343
3142
tako da bi to moglo uključivati
bolju kontrolu bolničkih infekcija
bolju kontrolu bolničkih infekcija
08:25
or vaccinating people,
194
493485
2895
ili cijepljenje ljudi,
08:28
particularly against
the seasonal influenza.
the seasonal influenza.
195
496380
2297
pogotovo protiv sezonske gripe.
08:30
And the seasonal flu is probably
196
498677
2531
Sezonska je, gripa vjerojatno,
08:33
the biggest driver of antibiotic use,
197
501208
3004
najveći pokretač upotrebe antibiotika,
08:36
both in this country as well
as in many other countries,
as in many other countries,
198
504212
2919
kako u ovoj zemlji, tako
i u mnogim drugim zemljama,
i u mnogim drugim zemljama,
08:39
and that could really help.
199
507131
2020
i to bi stvarno moglo pomoći.
08:41
A third option might include
something like tradeable permits.
something like tradeable permits.
200
509151
4103
Treća bi opcija mogla uključiti
nešto poput razmjenjivih kvota.
nešto poput razmjenjivih kvota.
08:45
And these seem like faraway scenarios,
201
513254
4246
Ovo se može činiti kao daleki scenarij,
08:49
but if you consider the
fact that we might not
fact that we might not
202
517500
2427
ali ako razmotrimo činjenicu da možda
08:51
have antibiotics for many
people who have infections,
people who have infections,
203
519927
3383
nećemo imati antibiotika
za mnoge ljude s infekcijama,
za mnoge ljude s infekcijama,
08:55
we might consider the fact that we might
204
523310
2237
mogli bi uzeti u obzir
činjenicu da bi možda
činjenicu da bi možda
08:57
want to allocate who actually gets to use
205
525547
2311
željeli raspodijeliti tko bi
trebao zapravo korisiti
trebao zapravo korisiti
08:59
some of these antibiotics over others,
206
527858
2714
neke od tih antibiotika od drugih,
09:02
and some of these might have to
be on the basis of clinical need,
be on the basis of clinical need,
207
530572
3326
i to bi mogli biti na bazi
kliničke potrebe
kliničke potrebe
09:05
but also on the basis of pricing.
208
533898
1935
ali i na bazi cijene.
09:07
And certainly consumer education works.
209
535833
1910
Zasigurno i educiranje potrošača pomaže.
09:09
Very often, people overuse antibiotics
210
537743
2601
Veoma često, ljudi
previše koriste antibiotike
previše koriste antibiotike
09:12
or prescribe too much without necessarily
211
540344
2277
ili previše propisuju bez da, nužno,
09:14
knowing that they do so,
212
542621
1606
znaju da to rade
pa su se mehanizmi koji
daju podatke o rezultatima
daju podatke o rezultatima
09:16
and feedback mechanisms
213
544227
1431
09:17
have been found to be useful,
214
545658
1902
pokazali korisnima,
09:19
both on energy —
215
547560
1929
također, i na energiji-
09:21
When you tell someone that they're using
216
549489
1540
kada kažete nekome da troši
09:23
a lot of energy during peak hour,
217
551029
1917
puno energije tijekom špice,
09:24
they tend to cut back,
218
552946
1470
skloni su smanjiti potrošnju,
09:26
and the same sort of example has been performed
219
554416
1767
i isti je primjer izveden
09:28
even in the case of antibiotics.
220
556183
1810
i u slučaju antibiotika.
Bolnica u St. Louisu bi, u biti, postavila
09:29
A hospital in St. Louis basically would put up
221
557993
1981
09:31
on a chart the names of surgeons
222
559974
4192
na tablu imena kirurga
poredana po tome koliko
su antibiotika koristili
su antibiotika koristili
09:36
in the ordering of how much antibiotics they'd used
223
564166
2219
09:38
in the previous month,
224
566385
1944
u prethodnom mjesecu,
09:40
and this was purely an
informational feedback,
informational feedback,
225
568329
2342
i to je čisto bila povratna informacija,
nije bilo nikakvog posramljivanja,
09:42
there was no shaming,
226
570671
1183
09:43
but essentially that provided
some information back
some information back
227
571854
2135
nego je, u osnovi, pružilo
neke informacije
neke informacije
09:45
to surgeons that maybe they could rethink
228
573989
1954
kirurzima i možda ih potaklo da razmisle
09:47
how they were using antibiotics.
229
575943
2229
kako koriste antibiotike.
09:50
Now, there's a lot that can be done
230
578172
2014
Također je mnogo toga moguće napraviti
09:52
on the supply side as well.
231
580186
2149
s aspekta opskrbe.
09:54
If you look at the price of penicillin,
232
582335
1777
Ako pogledate cijenu penicilina,
trošak po danu iznosi oko 10 centa.
09:56
the cost per day is about 10 cents.
233
584112
1651
09:57
It's a fairly cheap drug.
234
585763
1758
To je relativno jeftin lijek.
09:59
If you take drugs that have
been introduced since then —
been introduced since then —
235
587521
2137
Ako uzmete lijekove otkrivene od tada-
10:01
linezolid or daptomycin —
236
589658
2644
linezolid ili daptomicin-
10:04
those are significantly more expensive,
237
592302
1878
oni su značajno skuplji,
10:06
so to a world that has been used to
paying 10 cents a day for antibiotics,
paying 10 cents a day for antibiotics,
238
594180
5451
tako da se svijetu naviknutom plaćati
10 centi po danu za antibiotike,
10 centi po danu za antibiotike,
10:11
the idea of paying 180 dollars per day
239
599633
2530
ideja plaćanja 180 dolara po danu
10:14
seems like a lot.
240
602163
1567
čini puno.
10:15
But what is that really telling us?
241
603730
1987
No, što nam to zapravo govori?
10:17
That price is telling us
242
605717
1965
Cijena nam govori
10:19
that we should no longer
243
607682
1898
da više ne bi trebali
10:21
take cheap, effective
antibiotics as a given
antibiotics as a given
244
609580
4117
uzimati jeftine, učinkovite
antibiotike zdravo za gotovo
antibiotike zdravo za gotovo
10:25
into the foreseeable future,
245
613697
1767
u doglednoj budućnosti,
10:27
and that price is a signal to us
246
615464
2530
i cijena nam je signal
10:29
that perhaps we need to be paying
247
617994
1609
da bi možda trebali obraćati
10:31
much more attention to conservation.
248
619603
2553
puno više pažnje očuvanju.
10:34
That price is also a signal
249
622156
2704
Cijena je, također, signal
10:36
that maybe we need to start
looking at other technologies,
looking at other technologies,
250
624860
2875
da bi možda trebali početi
gledati na druge tehnologije,
gledati na druge tehnologije,
10:39
in the same way that
gasoline prices are a signal
gasoline prices are a signal
251
627735
2652
na isti način na koji su
cijene benzina signal
cijene benzina signal
10:42
and an impetus, to, say,
252
630387
2590
i pokretna sila za, na primjer,
10:44
the development of electric cars.
253
632977
1868
razvoj električnih auta.
10:46
Prices are important signals
254
634845
1777
Cijene su važan signal
10:48
and we need to pay attention,
255
636622
1586
i moramo obratiti pozornost,
10:50
but we also need to consider the fact that
256
638208
2452
ali, isto tako moramo
u obzir uzeti činjenicu da
u obzir uzeti činjenicu da
10:52
although these high prices
seem unusual for antibiotics,
seem unusual for antibiotics,
257
640660
4252
iako se ove visoke cijene čine
neobičnima za antibiotike,
neobičnima za antibiotike,
10:56
they're nothing compared to the price per day
258
644912
2239
zanemarive su u usporedbi
s dnevnim cijenama
s dnevnim cijenama
10:59
of some cancer drugs,
259
647151
1384
nekih lijekova za rak,
koji mogu spasiti pacijentov život samo
za nekoliko mjeseci ili možda godinu,
za nekoliko mjeseci ili možda godinu,
11:00
which might save a patient's life only
for a few months or perhaps a year,
for a few months or perhaps a year,
260
648535
3370
11:03
whereas antibiotics would potentially
261
651905
1770
dok bi antibiotici, potencijalno,
11:05
save a patient's life forever.
262
653675
1826
spasili pacijentov život zauvijek.
11:07
So this is going to involve
263
655501
1319
Tako da će ovo uključivati
11:08
a whole new paradigm shift,
264
656820
1962
potpuno novi preokret u pristupu,
to je, također, zastrašujuć preokret jer
11:10
and it's also a scary shift because
265
658782
1856
11:12
in many parts of this country,
266
660638
2329
u mnogim djelovima ove zemlje,
11:14
in many parts of the world,
267
662967
1744
u mnogim djelovima svijeta,
11:16
the idea of paying 200 dollars
268
664711
2069
ideja plaćanja 200 dolara
11:18
for a day of antibiotic treatment
269
666780
2891
za dan liječenja antibioticima
11:21
is simply unimaginable.
270
669671
2542
je jednostavno nezamisliva.
11:24
So we need to think about that.
271
672213
1734
Trebamo razmisliti o tome.
11:25
Now, there are backstop options,
272
673947
1813
Postoje opcije zaštitne mreže,
11:27
which is other alternative technologies
273
675760
2676
odnosno, druge alternativne tehnologije
11:30
that people are working on.
274
678436
1194
na kojima ljudi rade.
11:31
It includes bacteriophages, probiotics,
275
679630
2652
One uključuju bakteriofage, probiotike,
11:34
quorum sensing, synbiotics.
276
682282
4048
međustanična komunikacija, sinbiotici.
11:38
Now, all of these are useful avenues to pursue,
277
686330
3039
Sve su to korisni putevi
koje treba istražiti
koje treba istražiti
11:41
and they will become even more lucrative
278
689369
2610
i postati će još unosniji
11:43
when the price of new
antibiotics starts going higher,
antibiotics starts going higher,
279
691979
3081
kada cijena novih antibiotika počne rasti,
11:47
and we've seen that the
market does actually respond,
market does actually respond,
280
695060
2897
a vidjeli smo da tržište odgovara,
11:49
and the government is now considering
281
697957
2008
i vlada sada razmatra
11:51
ways of subsidizing new
antibiotics and development.
antibiotics and development.
282
699965
3767
načine poticanja razvoja novih antibiotika.
11:55
But there are challenges here.
283
703732
1723
Ali tu postoje izazovi.
11:57
We don't want to just throw money at a problem.
284
705455
1575
Ne želimo samo bacati novac.
11:59
What we want to be able to do
285
707030
1519
Želimo biti u mogućnosti
12:00
is invest in new antibiotics
286
708549
2279
uložiti u novi antibiotik
12:02
in ways that actually encourage
287
710828
2976
na načine da zapravo ohrabrimo
12:05
appropriate use and sales of those antibiotics,
288
713804
3020
umjesnu upotrebu i prodaju tih antibiotika,
12:08
and that really is the challenge here.
289
716824
2463
a upravo je to izazov.
12:11
Now, going back to these technologies,
290
719287
2329
Vraćajući se na te tehnologije,
12:13
you all remember the line from that famous
291
721616
2363
svi ćete se prisjetiti rečenice
iz onog poznatog
iz onog poznatog
12:15
dinosaur film, "Nature will find a way."
292
723979
2226
filma o dinosaurima: "Priroda će pronaći put."
12:18
So it's not as if these are
permanent solutions.
permanent solutions.
293
726205
3319
Tako da ovo nisu trajna rješenja.
12:21
We really have to remember that,
whatever the technology might be,
whatever the technology might be,
294
729524
4086
Stvarno to moramo zapamtiti,
kakva god tehnologija bila,
kakva god tehnologija bila,
12:25
that nature will find some
way to work around it.
way to work around it.
295
733610
2876
priroda će naći način kako ju izbjeći.
12:28
You might think, well,
this is just a problem
this is just a problem
296
736486
2071
Mogli bi pomisliti da je ovo problem
12:30
just with antibiotics and with bacteria,
297
738557
2744
samo sa antibioticima i bakterijama,
12:33
but it turns out that we
have the exact same
have the exact same
298
741301
1946
ali ispostavilo se da imamo točno isti,
12:35
identical problem in
many other fields as well,
many other fields as well,
299
743247
2734
identični problem i
u mnogim drugim područjima,
u mnogim drugim područjima,
12:37
with multidrug-resistant tuberculosis,
300
745981
2952
s tuberkulozom otpornom na više lijekova,
12:40
which is a serious problem
in India and South Africa.
in India and South Africa.
301
748933
3562
što je ozbiljan problem
u Indiji i Južnoj Africi.
u Indiji i Južnoj Africi.
12:44
Thousands of patients are dying because
302
752495
1787
Tisuće pacijenata umire jer
12:46
the second-line drugs are so expensive,
303
754282
1834
su zamjenski lijekovi toliko skupi,
12:48
and in some instances, even those don't work
304
756116
2227
a, u nekim slučajevima, ni oni ne djeluju
12:50
and you have XDR TB.
305
758343
2070
i imate ekstremno otpornu tuberkulozu.
12:52
Viruses are becoming resistant.
306
760413
1811
Virusi postaju rezistentni.
12:54
Agricultural pests. Malaria parasites.
307
762224
3166
Poljoprivredni štetnici. Paraziti malarije.
12:57
Right now, much of the world depends on
308
765390
1783
Trenutno, veliki dio svijeta ovisi o
12:59
one drug, artemisinin drugs,
309
767173
3697
jednom lijeku, artemisininima,
13:02
essentially to treat malaria.
310
770870
1956
za liječenje malarije.
13:04
Resistance to artemisinin has already emerged,
311
772826
2587
Otpornost na artemisinin se već pojavila
13:07
and if this were to become widespread,
312
775413
2354
i ako ona postane široko rasprostranjena,
13:09
that puts at risk
313
777767
1348
riskiramo
13:11
the single drug that we have to
treat malaria around the world
treat malaria around the world
314
779115
2891
jedini lijek koji imamo za liječenje
malarije širom svijeta
malarije širom svijeta
13:14
in a way that's currently
safe and efficacious.
safe and efficacious.
315
782006
3214
na siguran i efikasan način.
13:17
Mosquitos develop resistance.
316
785220
1798
Komarci razvijaju otpornost.
13:19
If you have kids, you probably
know about head lice,
know about head lice,
317
787018
2237
Ako imate djecu, vjerojatno znate za uši,
13:21
and if you're from New York City,
318
789255
1713
a ako ste iz New Yorka,
13:22
I understand that the
specialty there is bedbugs.
specialty there is bedbugs.
319
790968
2733
znam da su tamo specijalnost stjenice.
13:25
So those are also resistant.
320
793701
2255
One su također rezistentne.
13:27
And we have to bring an
example from across the pond.
example from across the pond.
321
795956
2879
Moramo proučiti i primjer preko bare.
13:30
Turns out that rats are
also resistant to poisons.
also resistant to poisons.
322
798835
2355
Ispada da su i štakori otporni na otrove.
13:33
Now, what's common
to all of these things is
to all of these things is
323
801190
2701
Ono što je zajedničko
svim ovim stvarima je
svim ovim stvarima je
13:35
the idea that we've had these technologies
324
803891
2706
da smo imali ove tehnologije
13:38
to control nature only for
the last 70, 80 or 100 years
the last 70, 80 or 100 years
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za kontrolu prirode samo za
proteklih 70, 80 ili 100 godina
proteklih 70, 80 ili 100 godina
13:43
and essentially in a blink,
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i u trenutku
13:46
we have squandered our ability to control,
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smo potratili našu mogućnost kontrole,
13:48
because we have not recognized
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jer nismo prepoznali da će
13:51
that natural selection and
evolution was going to find
evolution was going to find
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prirodna selekcija i evolucija pronaći
13:54
a way to get back,
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način da se osveti,
13:55
and we need to completely rethink
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i moramo potpuno promisliti
13:57
how we're going to use
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kako ćemo koristiti
13:59
measures to control biological organisms,
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mjere za kontrolu bioloških organizama,
14:02
and rethink how we incentivize
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i promisliti kako ćemo poticati
14:06
the development, introduction,
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razvoj, uvođenje,
14:08
in the case of antibiotics prescription,
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u slučaju propisivanja antibiotika
14:11
and use of these valuable resources.
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i korištenje vrijednih resursa.
14:14
And we really now need to
start thinking about them
start thinking about them
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I sada stvarno trebamo
početi razmišljati o njima
početi razmišljati o njima
14:17
as natural resources.
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kao o prirodnim resursima.
14:19
And so we stand at a crossroads.
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I tako stojimo na raskrižju.
14:21
An option is to go through that rethinking
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Opcija je proći kroz ta razmišljanja
14:24
and carefully consider incentives
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i pažljivo razmotriti poticaje
14:26
to change how we do business.
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kako bi promijenili način poslovanja.
14:28
The alternative is
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Alternativa je
14:31
a world in which even a blade of grass
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svijet u kojem je čak i vlat trave
14:34
is a potentially lethal weapon.
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potencijalno smrtonosno oružje.
14:36
Thank you.
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Hvala.
14:38
(Applause)
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(Pljesak)
ABOUT THE SPEAKER
Ramanan Laxminarayan - Drug-resistance economistAt the Center for Disease Dynamics, Economics & Policy, economist Ramanan Laxminarayan looks at big-picture issues of global health.
Why you should listen
Economist Ramanan Laxminarayan works to improve understanding of drug resistance as a problem of managing a shared global resource. As Director and Senior Fellow at the Center for Disease Dynamics, Economics & Policy (CDDEP), he is interested in cross-disciplinary, pragmatic solutions to reduce drug resistance. He has advised the World Health Organization and World Bank on evaluating malaria treatment policy, vaccination strategies, the economic burden of tuberculosis, and control of non-communicable diseases. He was a key architect of the Affordable Medicines Facility for malaria, a novel financing mechanism to improve access and delay resistance to antimalarial drugs. In 2012, he created the Immunization Technical Support Unit in India, which has been credited with improving the immunization program in the country. He teaches at Princeton.
As he says: "It has been a long time since people died of untreatable bacterial infections, and the prospect of returning to that world is worrying."Ramanan Laxminarayan | Speaker | TED.com