TEDMED 2014
Ramanan Laxminarayan: The coming crisis in antibiotics
Rimonan Lakšminarajan (Ramanan Laxminarayan): Nadolazeća kriza u sferi antibiotika
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Antibiotici spašavaju živote. Ali mi ih naprosto previše koristimo - i to često u slučajevima u kojima nije ugrožen život, poput lečenja gripa ili čak uzgajanja jeftinijih pilića. Ono što sledi je da će, po rečima istraživača Rimonana Lakšminarajana, ovi lekovi potpuno prestati da deluju, pošto bakterije postaju sve otpornije. On nam svima upućuje poziv (kako pacijentima, tako i lekarima) da o antibioticima - i njihovoj delotvornosti - mislimo kao o krajnjoj meri, i da dva puta razmislimo pre nego što ih upotrebimo. To je otrežnjujući pogled na to kako globalni medicinski trendovi mogu da nas lično pogode.
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 ikada lečen antibiotikom
00:16
was a policeman in Oxford.
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je bio oksfordski policajac.
00:17
On his day off from work,
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On se tokom slobodnog dana,
00:19
he was scratched by a rose thorn
while working in the garden.
while working in the garden.
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radeći u bašti, ogrebao o ružin trn.
00:23
That small scratch became infected.
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Ta mala ogrebotina se inficirala.
00:26
Over the next few days,
his head was swollen
his head was swollen
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Tokom nekoliko narednih dana,
čitava glava mu je bila otečena
čitava glava mu je bila otečena
00:29
with abscesses,
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gnojnim čirevima,
00:30
and in fact his eye was so infected
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a oko mu je bilo toliko inficirano
00:33
that they had to take it out,
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da su morali da ga izvade,
00:35
and by February of 1941,
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te je do februara 1941,
00:38
this poor man was on the verge of dying.
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ovaj jadan čovek bio na rubu smrti.
00:40
He was at Radcliffe Infirmary in Oxford,
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Bio je u ambulanti Redklif u Oksfordu,
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 lekara
00:47
led by a Dr. Howard Florey
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predvođen dr Hauardom Florijem
00:48
had managed to synthesize
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je uspeo da sintetizuje
00:50
a very small amount of penicillin,
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jako malu količinu penicilina,
00:53
a drug that had been discovered
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leka koji je 12 godina ranije
00:55
12 years before by Alexander Fleming
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otkrio Aleksandar Fleming
00:58
but had never actually been
used to treat a human,
used to treat a human,
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ali koji nikada nije bio korišćen
u lečenju ljudi,
u lečenju ljudi,
01:01
and indeed no one even
knew if the drug would work,
knew if the drug would work,
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i zaista niko nije znao
ni da li će lek delovati,
ni da li će lek delovati,
01:04
if it was full of impurities
that would kill the patient,
that would kill the patient,
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da li je pun nečistoća
koje bi ubile pacijenta,
koje bi ubile pacijenta,
01:07
but Florey and his team figured
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ali su Florej i njegov tim računali
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 treba da ga upotrebe,
01:11
on someone who was going to die anyway.
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onda bolje da ga daju nekome
ko će svakako umreti.
ko će svakako umreti.
01:14
So they gave Albert Alexander,
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Tako da su Albertu Aleksandru,
01:17
this Oxford policeman, the drug,
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tom oksfordskom policajcu, dali lek
01:20
and within 24 hours,
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i tokom 24 sata,
01:23
he started getting better.
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počelo je da mu postaje bolje.
01:25
His fever went down,
his appetite came back.
his appetite came back.
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Pala mu je temperatura,
povratio se apetit.
povratio se apetit.
01:29
Second day, he was doing much better.
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Drugog dana mu je bilo znatno bolje.
01:31
They were starting to
run out of penicillin,
run out of penicillin,
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Počelo je da im ponestaje penicilina,
01:33
so what they would do
was run with his urine
was run with his urine
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i oni bi sa njegovim urinom
trčali na drugu stranu ulice, kako bi
iz urina resintetizovali penicilin
iz urina resintetizovali penicilin
01:35
across the road to re-synthesize
the penicillin from his urine
the penicillin from his urine
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01:38
and give it back to him,
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i ponovo mu ga dali,
01:40
and that worked.
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i to je dalo rezultate.
01:42
Day four, well on the way to recovery.
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Četvrtog dana, uveliko na putu izlečenja.
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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Petog dana im je nestalo penicilina
01:50
and the poor man died.
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i ovaj nesrećni čovek je umro.
01:52
So that story didn't end that well,
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Tako da ta priča nema srećan kraj,
01:55
but fortunately for
millions of other people,
millions of other people,
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ali na sreću miliona drugih ljudi,
01:59
like this child who was treated
again in the early 1940s,
again in the early 1940s,
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poput ovog deteta koje je lečeno
ranih 1940-ih,
ranih 1940-ih,
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 tokom samo šest dana,
kao što vidite,
kao što vidite,
02:08
recovered thanks to this
wonder drug, penicillin.
wonder drug, penicillin.
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oporavilo zahvaljujući
tom magičnom leku, penicilinu.
tom magičnom leku, penicilinu.
02:12
Millions have lived,
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Milioni su preživeli,
02:14
and global health has been transformed.
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i globalno zdravlje je bilo promenjeno.
02:17
Now, antibiotics have been used
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Antibioticima su lečeni
02:20
for patients like this,
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pacijenti poput ovih,
02:23
but they've also been
used rather frivolously
used rather frivolously
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ali su korišćeni i prilično lakomisleno
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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kako bi se pacijenti lečili
od samo prehlade ili gripa,
od samo prehlade ili gripa,
02:29
which they might not have
responded to an antibiotic,
responded to an antibiotic,
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na koje antibiotici možda i nisu delovali,
02:32
and they've also been
used in large quantities
used in large quantities
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a i korišćeni su u velikim količinama
02:36
sub-therapeutically, which
means in small concentrations,
means in small concentrations,
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neterapeutski, što znači
u maloj koncentraciji,
u maloj koncentraciji,
02:39
to make chicken and hogs grow faster.
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kako bi se ubrzao rast kokoški 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 zarad uštede
od nekoliko penija na ceni mesa,
od nekoliko penija na ceni mesa,
02:46
we've spent a lot of
antibiotics on animals,
antibiotics on animals,
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potrošili smo velike količine
antibiotika na životinje,
antibiotika na životinje,
02:49
not for treatment, not for sick animals,
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ne radi lečenja, ne na bolesne životinje,
02:51
but primarily for growth promotion.
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već prvenstveno radi ubrzavanja rasta.
02:54
Now, what did that lead us to?
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I gde nas je to dovelo?
02:57
Basically, the massive use of antibiotics
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Suštinski, velika upotreba antibiotika
03:00
around the world
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širom sveta
03:01
has imposed such large
selection pressure on bacteria
selection pressure on bacteria
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je bakterijama nametnula
tako oštru selekciju
tako oštru selekciju
03:05
that resistance is now a problem,
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da je danas problem otpornost,
03:08
because we've now selected for just
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jer smo sada selektovali
03:10
the resistant bacteria.
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samo otporne 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 o ovome
čitali u novinama,
čitali u novinama,
03:14
you've seen this in every magazine
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videli u svakom magazinu
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 zaista želim da pravilno shvatite
03:20
the significance of this problem.
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značaj 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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Sledeći slajd koji ću vam pokazati je
otpornost acinetobaktera na karbapenem.
otpornost acinetobaktera na karbapenem.
03:28
Acinetobacter is a nasty hospital bug,
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Acinetobakter je opasan bolnički bacil,
03:31
and carbapenem is pretty much
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a karbapenem je gotovo
03:32
the strongest class of antibiotics
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najjača klasa antibiotika
03:34
that we can throw at this bug.
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kojom bismo mogli da ga napadnemo.
03:36
And you can see in 1999
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I vidite 1999.
03:39
this is the pattern of resistance,
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ovo je model otpornosti,
03:42
mostly under about 10 percent
across the United States.
across the United States.
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uglavnom ispod 10 procenata
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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A sada pogledajte šta se dešava
kada pustimo video.
kada pustimo video.
03:58
So I don't know where you live,
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Ne znam gde živite,
04:00
but wherever it is, it certainly is a lot worse now
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ali gde god to bilo,
sada je sigurno daleko lošije
sada je sigurno daleko lošije
04:03
than it was in 1999,
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nego što je bilo 1999,
04:05
and that is the problem of antibiotic resistance.
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i to je problem otpornosti na antibiotike.
04:09
It's a global issue
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To je globalno pitanje
04:11
affecting both rich and poor countries,
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koje pogađa 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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možda ćete reći, pa suštinski,
04:16
isn't this really just a medical issue?
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zar to nije zapravo medicinski problem?
04:18
If we taught doctors how not
to use antibiotics as much,
to use antibiotics as much,
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Ukoliko naučimo lekare da
ne koriste tako mnogo antibiotike,
ne koriste tako mnogo antibiotike,
04:20
if we taught patients how
not to demand antibiotics,
not to demand antibiotics,
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ukoliko naučimo pacijente da ih ne traže,
04:23
perhaps this really wouldn't be an issue,
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možda to zaista i 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 da rade napornije
04:28
more antibiotics.
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na razvijanju novih antibiotika.
04:30
Now, it turns out that there's something
fundamental about antibiotics
fundamental about antibiotics
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Ispostavilo se da je kod antibiotika
nešto temeljno drugačije
nešto temeljno drugačije
04:33
which makes it different from other drugs,
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nego kod drugih lekova,
04:35
which is that if I misuse antibiotics
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a to je da moje zloupotrebljavanje
04:37
or I use antibiotics,
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ili upotrebljavanje antibiotika,
04:39
not only am I affected but
others are affected as well,
others are affected as well,
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neće samo uticati na mene, već i na druge,
04:43
in the same way as if I
choose to drive to work
choose to drive to work
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baš kao i moja odluka
da na posao idem kolima
da na posao idem kolima
04:45
or take a plane to go somewhere,
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ili da nekuda letim avionom,
04:48
that the costs I impose on others
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cena koju drugima namećem
04:50
through global climate change go everywhere,
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kroz globalnu promenu klime ide svuda,
04:52
and I don't necessarily take
these costs into consideration.
these costs into consideration.
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a nije izvesno da tu cenu
uzimam u razmatranje.
uzimam u razmatranje.
To je ono što bi ekonomisti mogli nazvati
problemom zajedničkih dobara
problemom zajedničkih dobara
04:55
This is what economists might
call a problem of the commons,
call a problem of the commons,
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04:58
and the problem of the commons is exactly
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a problem zajedničkih dobara
05:00
what we face in the case
of antibiotics as well:
of antibiotics as well:
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je upravo ono sa čime se suočavamo
i u slučaju antibiotika:
i u slučaju antibiotika:
05:02
that we don't consider —
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da mi ne uzimamo u obzir -
05:04
and we, including individuals, patients,
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a "mi" uključuje: pojedince, pacijente,
05:07
hospitals, entire health systems —
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bolnice, čitave zdravstvene sisteme -
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 cenu koju
namećemo drugima
namećemo drugima
05:13
by the way antibiotics are actually used.
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načinom na koji se koriste antibiotici.
05:15
Now, that's a problem that's similar
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To je problem sličan
05:17
to another area that we all know about,
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drugoj oblasti koju svi poznajemo,
05:19
which is of fuel use and energy,
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a to je korišćenje goriva i energije,
05:21
and of course energy use
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i naravno korišćenje energije
05:23
both depletes energy as well as
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crpi energiju
05:26
leads to local pollution
and climate change.
and climate change.
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i vodi ka lokalnom zagađenju
i klimatskim promenama.
i klimatskim promenama.
05:29
And typically, in the case of energy,
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A u slučaju energije, tipično
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
možete da se nosite sa problemom.
možete da se nosite sa 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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Prvi 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 istovetno 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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i to možemo da činimo na različite načine
05:42
that we'll talk about in a second,
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o kojima ćemo uskoro govoriti,
05:45
but the other option is the
"drill, baby, drill" option,
"drill, baby, drill" option,
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a druga mogućnost je:
"drill, baby, drill" opcija,
"drill, baby, drill" opcija,
05:48
which in the case of antibiotics
is to go find new antibiotics.
is to go find new antibiotics.
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što u slučaju antibiotika znači
pronalaženje novih antibiotika.
pronalaženje novih antibiotika.
05:53
Now, these are not separate.
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Ovo nije razdvojivo.
05:55
They're related, because if we invest heavily
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Povezano je, jer ukoliko
značajno investiramo
značajno investiramo
05:58
in new oil wells,
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u nova naftna polja,
06:00
we reduce the incentives
for conservation of oil
for conservation of oil
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smanjujemo podstrek očuvanju nafte
06:03
in the same way that's going
to happen for antibiotics.
to happen for antibiotics.
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na isti način koji će se dogoditi
u slučaju antibiotika.
u slučaju antibiotika.
06:06
The reverse is also going
to happen, which is that
to happen, which is that
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Dogodiće se i obrnuti slučaj,
06:08
if we use our antibiotics appropriately,
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da ukoliko antibiotike koristimo
na odgovarajući način,
na odgovarajući način,
06:10
we don't necessarily have
to make the investments
to make the investments
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ne moramo nužno da investiramo
06:13
in new drug development.
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u razvijanje novih lekova.
06:15
And if you thought that these two were entirely,
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I ukoliko ste mislili da su
ove dve mogućnosti
ove dve mogućnosti
06:18
fully balanced between these two options,
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u potpunosti uravnotežene,
06:20
you might consider the fact that
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možete uzeti u obzir činjenicu
06:22
this is really a game that we're playing.
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da je to zapravo igra koju igramo.
06:24
The game is really one of coevolution,
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To je igra koevolucije,
06:27
and coevolution is, in
this particular picture,
this particular picture,
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a koevolucija je, na ovoj
konkretnoj fotografiji
konkretnoj fotografiji
06:30
between cheetahs and gazelles.
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između geparda i gazela.
06:32
Cheetahs have evolved to run faster,
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Gepard je evoluirao da brže trči,
06:34
because if they didn't run faster,
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jer ukoliko ne trči brže,
06:35
they wouldn't get any lunch.
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neće dobiti ručak.
06:37
Gazelles have evolved to run faster because
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Gazele su evoluirale da trče brže
06:40
if they don't run faster, they would be lunch.
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jer ukoliko ne trče brže, postaće ručak.
06:43
Now, this is the game we're
playing against the bacteria,
playing against the bacteria,
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Dakle, ovo je igra
koju igramo sa bakterijama,
koju igramo sa bakterijama,
06:46
except we're not the cheetahs,
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izuzev što mi nismo gepardi,
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 tokom ovog kratkog govora,
06:54
would have had kids and grandkids
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dobila decu i unuke
06:55
and figured out how to be resistant
157
403975
2385
i shvatila kako da bude otporna
06:58
just by selection and trial and error,
158
406360
2474
samo selekcijom i
proverom raznih mogućnosti,
proverom raznih mogućnosti,
07:00
trying it over and over again.
159
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1912
upornim pokušavanjem.
07:02
Whereas how do we stay
ahead of the bacteria?
ahead of the bacteria?
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3772
A kako da preduhitrimo bakteriju?
07:06
We have drug discovery processes,
161
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2054
Imamo procese otkrivanja lekova,
07:08
screening molecules,
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1630
ispitivanje molekula,
07:10
we have clinical trials,
163
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1728
imamo klinička testiranja,
07:11
and then, when we think we have a drug,
164
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2148
a onda, kada mislimo da imamo lek,
07:14
then we have the FDA regulatory process.
165
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3745
tada imamo regulatorni proces
Uprave za hranu i lekove (FDA)
Uprave za hranu i lekove (FDA)
07:17
And once we go through all of that,
166
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2178
I kada jednom prođemo kroz sve to,
07:20
then we try to stay one step ahead
167
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2265
tada pokušavamo da budemo
07:22
of the bacteria.
168
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2296
korak ispred bakterije.
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 ovo nije održiva igra,
ili igra u kojoj možemo da pobedimo
07:27
or one that we can win
170
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1137
07:28
by simply innovating to stay ahead.
171
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1837
koristeći samo inovaciju.
07:30
We've got to slow the pace of coevolution down,
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3305
Moramo da usporimo ritam koevolucije,
07:33
and there are ideas that we
can borrow from energy
can borrow from energy
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3682
a postoje ideje koje možemo
da pozajmimo od energetike,
da pozajmimo od energetike,
07:37
that are helpful in thinking about
174
445300
1770
i koje su korisne u razmišljanjima
07:39
how we might want to do this in the case
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1537
o tome kako da postupimo
07:40
of antibiotics as well.
176
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1546
i u slučaju antibiotika.
07:42
Now, if you think about how we deal with
177
450153
2240
Ukoliko razmislite o tome kako formiramo
07:44
energy pricing, for instance,
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1423
cene energenata, na primer,
07:45
we consider emissions taxes,
179
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1849
mi uračunavamo takse za zagađenje,
07:47
which means we're imposing
the costs of pollution
the costs of pollution
180
455665
2584
što znači da cenu zagađenja naplaćujemo
07:50
on people who actually use that energy.
181
458249
2831
ljudima koji koriste tu energiju.
07:53
We might consider doing that for antibiotics as well,
182
461080
2980
Mogli bismo da razmislimo da isto
učinimo sa antibioticima,
učinimo sa antibioticima,
07:56
and perhaps that would make sure that antibiotics
183
464060
2711
i možda bi to obezbedilo
07:58
actually get used appropriately.
184
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2401
odgovarajuću upotrebu antibiotika.
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
što znači prelazak na korišćenje
goriva koja manje zagađuju
goriva koja manje zagađuju
08:06
or perhaps don't need fossil fuels.
187
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2845
ili koja nisu fosilna goriva.
08:09
Now, the analogy here is, perhaps we need
188
477100
2860
Ovde je analogija da možda treba
08:11
to move away from using antibiotics,
189
479960
2260
da manje koristimo antibiotike
08:14
and if you think about it, what are
good substitutes for antibiotics?
good substitutes for antibiotics?
190
482220
3716
i ako o tome razmislite, koja je
dobra alternativa antibioticima?
dobra alternativa antibioticima?
08:17
Well, turns out that anything that reduces
191
485936
2164
Pa, ispada da bi delovalo sve što smanjuje
08:20
the need for the antibiotic would really work,
192
488100
2243
potrebu za upotrebom antibiotika,
08:22
so that could include improving
hospital infection control
hospital infection control
193
490343
3142
a to uključuje i poboljšanje kontrole
bolničkih infekcija
bolničkih infekcija
08:25
or vaccinating people,
194
493485
2895
ili vakcinisanje,
08:28
particularly against
the seasonal influenza.
the seasonal influenza.
195
496380
2297
naročito protiv sezonskog gripa.
08:30
And the seasonal flu is probably
196
498677
2531
A sezonski grip je verovatno
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 tako i u mnogim
drugim zemljama,
drugim zemljama,
08:39
and that could really help.
199
507131
2020
i to bi zaista moglo da pomogne.
08:41
A third option might include
something like tradeable permits.
something like tradeable permits.
200
509151
4103
A treća mogućnost bi mogla da uključi
nešto poput dozvola koje bi se prodavale.
nešto poput dozvola koje bi se prodavale.
08:45
And these seem like faraway scenarios,
201
513254
4246
A one se čine poput
jako udaljenih mogućnosti,
jako udaljenih mogućnosti,
08:49
but if you consider the
fact that we might not
fact that we might not
202
517500
2427
ali ukoliko uzmete u obzir
činjenicu da možda
činjenicu da možda
08:51
have antibiotics for many
people who have infections,
people who have infections,
203
519927
3383
nećemo imati antibiotike za
mnoge ljude sa infekcijama,
mnoge ljude sa infekcijama,
08:55
we might consider the fact that we might
204
523310
2237
možda treba da razmislimo o tome
08:57
want to allocate who actually gets to use
205
525547
2311
da bismo možda želeli da odredimo ko će
08:59
some of these antibiotics over others,
206
527858
2714
koristiti koje antibiotike,
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 neke od ovih odluka će biti zasnovane
na kliničkim potrebama,
na kliničkim potrebama,
09:05
but also on the basis of pricing.
208
533898
1935
ali i na osnovu cene.
I svakako da obrazovanje
potrošača daje rezultate.
potrošača daje rezultate.
09:07
And certainly consumer education works.
209
535833
1910
09:09
Very often, people overuse antibiotics
210
537743
2601
Vrlo često ljudi prekomerno
koriste antibiotike
koriste antibiotike
09:12
or prescribe too much without necessarily
211
540344
2277
ili ih previše prepisuju
a da toga nisu svesni, tako da su se
09:14
knowing that they do so,
212
542621
1606
09:16
and feedback mechanisms
213
544227
1431
mehanizmi informisanja
09:17
have been found to be useful,
214
545658
1902
pokazali korisnima,
09:19
both on energy —
215
547560
1929
kao i kod energije -
09:21
When you tell someone that they're using
216
549489
1540
kada nakome kažete da koristi
09:23
a lot of energy during peak hour,
217
551029
1917
previše energije u udarnom terminu,
09:24
they tend to cut back,
218
552946
1470
on obično smanjuje potrošnju,
09:26
and the same sort of example has been performed
219
554416
1767
a slični primeri su korišćeni
09:28
even in the case of antibiotics.
220
556183
1810
čak i u slučaju antibiotika.
09:29
A hospital in St. Louis basically would put up
221
557993
1981
Bolnica u Sent Luisu bi istakla grafikon
09:31
on a chart the names of surgeons
222
559974
4192
sa imenima hirurga
09:36
in the ordering of how much antibiotics they'd used
223
564166
2219
rangiranih po upotrebi antibiotika
09:38
in the previous month,
224
566385
1944
tokom prethodnog meseca,
09:40
and this was purely an
informational feedback,
informational feedback,
225
568329
2342
ovo je bilo čisto informativne prirode,
09:42
there was no shaming,
226
570671
1183
nije bilo okrivljavanja,
09:43
but essentially that provided
some information back
some information back
227
571854
2135
ali je hirurzima pružalo informaciju
09:45
to surgeons that maybe they could rethink
228
573989
1954
da bi možda mogli da razmisle
09:47
how they were using antibiotics.
229
575943
2229
o tome kako koriste antibiotike.
09:50
Now, there's a lot that can be done
230
578172
2014
Mnogo toga može da se uradi
09:52
on the supply side as well.
231
580186
2149
i na polju snabdevanja.
09:54
If you look at the price of penicillin,
232
582335
1777
Ukoliko pogledate cenu penicilina,
09:56
the cost per day is about 10 cents.
233
584112
1651
dnevni trošak iznosi 10 centi.
09:57
It's a fairly cheap drug.
234
585763
1758
To je prilično jeftin lek.
09:59
If you take drugs that have
been introduced since then —
been introduced since then —
235
587521
2137
Ukoliko posmatrate lekove
koji su uvedeni kasnije
koji su uvedeni kasnije
10:01
linezolid or daptomycin —
236
589658
2644
poput linezolida i daptomicina,
10:04
those are significantly more expensive,
237
592302
1878
oni su daleko 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 bi se svetu, naviknutom da dnevno
za antibiotike plaća 10 centi,
za antibiotike plaća 10 centi,
10:11
the idea of paying 180 dollars per day
239
599633
2530
dnevni trošak od 180 dolara
10:14
seems like a lot.
240
602163
1567
učinio veoma visokim.
10:15
But what is that really telling us?
241
603730
1987
Ali šta nam to zaista govori?
10:17
That price is telling us
242
605717
1965
Ta cena nam govori
10:19
that we should no longer
243
607682
1898
da više ne treba da,
u doglednoj budućnosti,
u doglednoj budućnosti,
10:21
take cheap, effective
antibiotics as a given
antibiotics as a given
244
609580
4117
jeftin i delotvoran antibiotik
uzimamo zdravo za gotovo
uzimamo zdravo za gotovo
10:25
into the foreseeable future,
245
613697
1767
10:27
and that price is a signal to us
246
615464
2530
a ta cena nam poručuje
10:29
that perhaps we need to be paying
247
617994
1609
da bismo možda trebali
10:31
much more attention to conservation.
248
619603
2553
da mnogo više obratimo pažnju na očuvanje.
10:34
That price is also a signal
249
622156
2704
Ova cena nam takođe poručuje
10:36
that maybe we need to start
looking at other technologies,
looking at other technologies,
250
624860
2875
da bismo možda trebali
da se okrenemo drugim tehnologijama,
da se okrenemo drugim tehnologijama,
10:39
in the same way that
gasoline prices are a signal
gasoline prices are a signal
251
627735
2652
baš kao što je cena goriva signal
10:42
and an impetus, to, say,
252
630387
2590
i takoreći, podsticaj
10:44
the development of electric cars.
253
632977
1868
razvoju električnih automobila.
10:46
Prices are important signals
254
634845
1777
Cene su značajni pokazatelji
i na njih moramo da obratimo pažnju,
10:48
and we need to pay attention,
255
636622
1586
10:50
but we also need to consider the fact that
256
638208
2452
ali u obzir moramo da uzmemo i činjenicu
10:52
although these high prices
seem unusual for antibiotics,
seem unusual for antibiotics,
257
640660
4252
da iako se ove cene čine
neobično visokim za antibiotike,
neobično visokim za antibiotike,
10:56
they're nothing compared to the price per day
258
644912
2239
one su ništavne u poređenju sa
dnevnim troškom
dnevnim troškom
nekih lekova protiv karcinoma,
10:59
of some cancer drugs,
259
647151
1384
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
koji pacijentu produžavaju život
za samo nekoliko meseci ili godinu dana,
za samo nekoliko meseci ili godinu dana,
11:03
whereas antibiotics would potentially
261
651905
1770
dok antibiotici imaju mogućnost
11:05
save a patient's life forever.
262
653675
1826
da pacijentu spasu život.
11:07
So this is going to involve
263
655501
1319
Tako da će ovo uključiti
11:08
a whole new paradigm shift,
264
656820
1962
i potpuno novu promenu ugla posmatranja,
11:10
and it's also a scary shift because
265
658782
1856
a to će biti i zastrašujuća promena
11:12
in many parts of this country,
266
660638
2329
jer je u mnogim delovima ove zemlje,
11:14
in many parts of the world,
267
662967
1744
kao i u mnogim delovima sveta,
11:16
the idea of paying 200 dollars
268
664711
2069
ideja o plaćanju 200 dolara
11:18
for a day of antibiotic treatment
269
666780
2891
za dan lečenja antibioticima
11:21
is simply unimaginable.
270
669671
2542
jednostavno nezamisliva.
Tako da o ovome moramo da razmislimo.
11:24
So we need to think about that.
271
672213
1734
11:25
Now, there are backstop options,
272
673947
1813
Postoje i poslednje mere
11:27
which is other alternative technologies
273
675760
2676
a to su druge alternativne tehnologije
11:30
that people are working on.
274
678436
1194
na kojima se radi.
11:31
It includes bacteriophages, probiotics,
275
679630
2652
One uključuju bakteriofage, probiotike,
11:34
quorum sensing, synbiotics.
276
682282
4048
osećaj kvoruma, sinbiotike.
11:38
Now, all of these are useful avenues to pursue,
277
686330
3039
To su sve korisna istraživanja,
11:41
and they will become even more lucrative
278
689369
2610
i ona će postati još unosnija
11:43
when the price of new
antibiotics starts going higher,
antibiotics starts going higher,
279
691979
3081
kada cena novih antibiotika
počne da raste,
počne da raste,
11:47
and we've seen that the
market does actually respond,
market does actually respond,
280
695060
2897
i vidimo da tržište zaista reaguje,
11:49
and the government is now considering
281
697957
2008
tako da Vlada sada razmatra
11:51
ways of subsidizing new
antibiotics and development.
antibiotics and development.
282
699965
3767
načine na koje bi mogla da dotira
razvijanje novih antibiotika.
razvijanje novih antibiotika.
Ali, ovde postoje i izazovi.
11:55
But there are challenges here.
283
703732
1723
Ne želimo da samo trošimo
velike količine novca.
velike količine novca.
11:57
We don't want to just throw money at a problem.
284
705455
1575
11:59
What we want to be able to do
285
707030
1519
Želimo da budemo u mogućnosti
12:00
is invest in new antibiotics
286
708549
2279
da investiramo u nove antibiotike
12:02
in ways that actually encourage
287
710828
2976
na način koji podstiče
12:05
appropriate use and sales of those antibiotics,
288
713804
3020
odgovarajuću upotrebu
i prodaju ovih antibiotika,
i prodaju ovih antibiotika,
12:08
and that really is the challenge here.
289
716824
2463
i tu leži izazov.
12:11
Now, going back to these technologies,
290
719287
2329
Vratimo se na ove tehnologije,
12:13
you all remember the line from that famous
291
721616
2363
svi se sećate rečenice iz onog poznatog
12:15
dinosaur film, "Nature will find a way."
292
723979
2226
filma o dinosaurusima:
"Priroda će pronači način".
"Priroda će pronači način".
12:18
So it's not as if these are
permanent solutions.
permanent solutions.
293
726205
3319
Tako da to nisu trajna rešenja.
12:21
We really have to remember that,
whatever the technology might be,
whatever the technology might be,
294
729524
4086
Moramo da upamtimo da,
kakva god bila ta tehnologija,
kakva god bila ta tehnologija,
12:25
that nature will find some
way to work around it.
way to work around it.
295
733610
2876
priroda će pronaći način
da se izbori sa njom.
da se izbori sa njom.
12:28
You might think, well,
this is just a problem
this is just a problem
296
736486
2071
Možete pomisliti, pa to je
samo problem
samo problem
12:30
just with antibiotics and with bacteria,
297
738557
2744
vezan za antibiotike i bakterije,
12:33
but it turns out that we
have the exact same
have the exact same
298
741301
1946
ali ispostavilo se da imamo
potpuno isti,
potpuno isti,
12:35
identical problem in
many other fields as well,
many other fields as well,
299
743247
2734
identičan problem i u mnogim
drugim oblastima,
drugim oblastima,
12:37
with multidrug-resistant tuberculosis,
300
745981
2952
sa tuberkulozom otpornom na
višestruke lekove,
višestruke lekove,
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
Hiljade pacijenata umire
jer je cena lekova druge linije
jako visoka,
jako visoka,
12:46
the second-line drugs are so expensive,
303
754282
1834
12:48
and in some instances, even those don't work
304
756116
2227
a u nekim slučajevima,
čak ni oni ne deluju
čak ni oni ne deluju
12:50
and you have XDR TB.
305
758343
2070
i imamo multirezistentnu tuberkulozu.
12:52
Viruses are becoming resistant.
306
760413
1811
Virusi postaju otporni.
12:54
Agricultural pests. Malaria parasites.
307
762224
3166
Poljoprivredne štetočine,
malarijski paraziti.
malarijski paraziti.
12:57
Right now, much of the world depends on
308
765390
1783
Trenutno se veći deo sveta
12:59
one drug, artemisinin drugs,
309
767173
3697
za lečenje malarije suštinski
13:02
essentially to treat malaria.
310
770870
1956
oslanja na jedan lek: artemisinin.
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 ukoliko se ona raširi,
13:09
that puts at risk
313
777767
1348
ugroziće jedini lek
13:11
the single drug that we have to
treat malaria around the world
treat malaria around the world
314
779115
2891
kojim malariju lečimo širom sveta
13:14
in a way that's currently
safe and efficacious.
safe and efficacious.
315
782006
3214
na sada bezbedan i efikasan način.
13:17
Mosquitos develop resistance.
316
785220
1798
Komarci postaju otporni.
Ukoliko imate decu, onda verovatno
znate o vaškama,
znate o vaškama,
13:19
If you have kids, you probably
know about head lice,
know about head lice,
317
787018
2237
13:21
and if you're from New York City,
318
789255
1713
a ukoliko ste iz Njujorka,
13:22
I understand that the
specialty there is bedbugs.
specialty there is bedbugs.
319
790968
2733
tamo su, koliko shvatam,
specijalnost stenice.
specijalnost stenice.
13:25
So those are also resistant.
320
793701
2255
I one su otporne.
13:27
And we have to bring an
example from across the pond.
example from across the pond.
321
795956
2879
Treba da damo primer i sa
druge strane okeana.
druge strane okeana.
13:30
Turns out that rats are
also resistant to poisons.
also resistant to poisons.
322
798835
2355
Ispostavilo se da su i pacovi
otporni na otrove.
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 svemu ovome
zajedničko je
zajedničko je
13:35
the idea that we've had these technologies
324
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2706
poimanje da mi sve 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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kojima kontrolišemo prirodu posedujemo
tek poslednjih 70, 80 ili 100 godina
tek poslednjih 70, 80 ili 100 godina
13:43
and essentially in a blink,
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a gotovo smo u trenutku,
13:46
we have squandered our ability to control,
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prokockali tu mogućnost da kontrolišemo,
13:48
because we have not recognized
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jer nismo uvideli
13:51
that natural selection and
evolution was going to find
evolution was going to find
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da će prirodna selekcija i evolucija
pronaći način
pronaći način
13:54
a way to get back,
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da uzvrate udarac,
13:55
and we need to completely rethink
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i moramo da ponovo temeljno razmislimo
13:57
how we're going to use
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o tome kako ćemo koristiti
13:59
measures to control biological organisms,
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mere kojima kontrolišemo
biološke organizme,
biološke organizme,
14:02
and rethink how we incentivize
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i kako podstičemo
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 antibiotika prepisivanje,
14:11
and use of these valuable resources.
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i korišćenje ovih dragocenih resursa.
14:14
And we really now need to
start thinking about them
start thinking about them
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I sada zaista moramo da počnemo
o njima da razmišljamo
o njima da razmišljamo
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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Mi se nalazimo na raskršću.
14:21
An option is to go through that rethinking
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Jedna mogućnosti je da razmislimo
14:24
and carefully consider incentives
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i pažljivo razmotrimo olakšice
14:26
to change how we do business.
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kojima ćemo da promenimo način rada.
14:28
The alternative is
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Alternativa je svet
14:31
a world in which even a blade of grass
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u kojem čak i vlat trave
14:34
is a potentially lethal weapon.
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može biti ubojito oružje.
14:36
Thank you.
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Hvala.
14:38
(Applause)
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(Aplauz)
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