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  • The first patient to ever be treated with an antibiotic

    第一位接受抗生素治療的患者

  • was a policeman in Oxford.

    是一位牛津的警察。

  • On his day off from work,

    有一天,他休假在家,

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

    整理自家花園時被玫瑰的刺劃傷。

  • That small scratch became infected.

    那個小的傷口被感染了。

  • Over the next few days, his head was swollen

    在接下來的幾天裡,他的頭因為膿瘡

  • with abscesses,

    而腫了起來,

  • and in fact his eye was so infected

    事實上他的眼睛受到嚴重感染,

  • that they had to take it out,

    醫生只好將它摘除,

  • and by February of 1941,

    到了 1941 年二月,

  • this poor man was on the verge of dying.

    這個可憐的警察 已經徘徊在生死邊緣。

  • He was at Radcliffe Infirmary in Oxford,

    他在牛津的拉德克利夫醫院接受治療,

  • and fortunately for him,

    幸運的是,

  • a small team of doctors

    由霍華德·佛洛里醫生

  • led by a Dr. Howard Florey

    領導的一個醫療小團隊

  • had managed to synthesize

    成功地合成了

  • a very small amount of penicillin,

    微量的青黴素,

  • a drug that had been discovered

    在 12 年前,由亞歷山大·佛萊明

  • 12 years before by Alexander Fleming

    所發現的一種藥物,

  • but had never actually been used to treat a human,

    但是從來沒有在人體上使用過,

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

    事實上,甚至沒人知道 這個藥是否有效,

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

    如果這藥物不純淨的話會不會致死,

  • but Florey and his team figured

    但是佛洛里和他的團隊覺得

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

    如果他們一定要試用這個藥,

  • on someone who was going to die anyway.

    不妨用在無藥可救的患者身上。

  • So they gave Albert Alexander,

    於是他們將藥用在亞柏·亞歷山大

  • this Oxford policeman, the drug,

    那位牛津警察的身上。

  • and within 24 hours,

    在 24 小時之內,

  • he started getting better.

    他的狀況開始好轉。

  • His fever went down, his appetite came back.

    他的燒退了,胃口也恢復了。

  • Second day, he was doing much better.

    第二天,他康復得更好。

  • They were starting to run out of penicillin,

    不過青黴素就快用完,

  • so what they would do was run with his urine

    所以醫生們採集他的尿液

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

    從尿液裡重新合成青黴素,

  • and give it back to him,

    再用來治療他,

  • and that worked.

    這個方法也可行。

  • Day four, well on the way to recovery.

    第四天,他仍在慢慢康復。

  • This was a miracle.

    在當時這是一個奇蹟。

  • Day five, they ran out of penicillin,

    第五天,青黴素用完了,

  • and the poor man died.

    那位可憐的警察就這樣去世了。

  • So that story didn't end that well,

    這個故事的結局不太好,

  • but fortunately for millions of other people,

    不過,在他之後,有百萬人受益,

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

    就像是 40 年代初期,

  • who was again dying of a sepsis,

    在敗血症下垂死掙扎的這個孩子,

  • and within just six days, you can see,

    你們可以看到,在六天之內,

  • recovered thanks to this wonder drug, penicillin.

    因為神奇的青黴素,這孩子痊癒了。

  • Millions have lived,

    上百萬的人因它活了下來,

  • and global health has been transformed.

    全人類的健康發生了轉變。

  • Now, antibiotics have been used

    現在,抗生素用來

  • for patients like this,

    治療這類病人,

  • but they've also been used rather frivolously

    但是它們也被輕易用在

  • in some instances,

    別的情況下,

  • for treating someone with just a cold or the flu,

    比如說用來治療感冒和流感,

  • which they might not have responded to an antibiotic,

    抗生素的治療效果不會很明顯。

  • and they've also been used in large quantities

    它們也被大量地使用在 非醫療場合裡,

  • sub-therapeutically, which means in small concentrations,

    用低濃度的抗生素,

  • to make chicken and hogs grow faster.

    讓雞和豬長得更快一些。

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

    只是為了省一些的買肉的錢,

  • we've spent a lot of antibiotics on animals,

    我們在動物身上用很多的抗生素,

  • not for treatment, not for sick animals,

    不是為了醫治生病的動物,

  • but primarily for growth promotion.

    主要是為了加速生長,

  • Now, what did that lead us to?

    這會導致什麼結果呢?

  • Basically, the massive use of antibiotics

    在全球

  • around the world

    大量地使用抗生素,

  • has imposed such large selection pressure on bacteria

    促進了細菌適者生存的自然選擇,

  • that resistance is now a problem,

    現在細菌的抗藥性成了問題,

  • because we've now selected for just

    因為只有抗藥性強的細菌

  • the resistant bacteria.

    才能生存到現在。

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

    我敢肯定你們都在報紙上 看過類似報導,

  • you've seen this in every magazine

    你們瀏覽的每一本雜誌

  • that you come across,

    都有看過類似文章,

  • but I really want you to appreciate

    但是我想讓你們明白

  • the significance of this problem.

    這個問題的重要性。

  • This is serious.

    這是一個很嚴重的問題。

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

    下一張幻燈片展示的是 不動桿菌對碳青黴烯的抗藥性,

  • Acinetobacter is a nasty hospital bug,

    不動桿菌是一種經常 存在於醫院的細菌,

  • and carbapenem is pretty much

    碳青黴烯是

  • the strongest class of antibiotics

    一種最強的抗生素

  • that we can throw at this bug.

    用來對抗這種細菌。

  • And you can see in 1999

    你們可以看到,在 1999 年

  • this is the pattern of resistance,

    這是抗藥性分布圖,

  • mostly under about 10 percent across the United States.

    在美國通常是在 10% 以下。

  • Now watch what happens when we play the video.

    接下來隨著時間推移會發生什麼。

  • So I don't know where you live,

    我不知道各位是住在哪裡

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

    不管你住在哪裡,現在的情況

  • than it was in 1999,

    都比 1999 年要差,

  • and that is the problem of antibiotic resistance.

    問題所在就是對抗生素的抗藥性。

  • It's a global issue

    這是一個全球性的問題

  • affecting both rich and poor countries,

    富有和貧窮國家都受到了影響,

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

    歸根結底,你也許會說,

  • isn't this really just a medical issue?

    這只是一個醫學問題吧?

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

    如果我們讓醫生少用抗生素,

  • if we taught patients how not to demand antibiotics,

    讓病人不要求使用抗生素,

  • perhaps this really wouldn't be an issue,

    不就化解難題了嘛,

  • and maybe the pharmaceutical companies

    也許醫藥公司

  • should be working harder to develop

    應該更努力研發

  • more antibiotics.

    更多的抗生素。

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

    但是抗生素在本質上

  • which makes it different from other drugs,

    與其他藥物有不同的地方,

  • which is that if I misuse antibiotics

    意味著,如果我誤用抗生素

  • or I use antibiotics,

    或使用抗生素,

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

    不僅我會受到影響, 其他人也會受到影響,

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

    同理,有如我開車去上班

  • or take a plane to go somewhere,

    或者坐飛機去別的地方,

  • that the costs I impose on others

    我造成的污染也會影響到別人

  • through global climate change go everywhere,

    因此造成氣候變化 其影響無所不在,

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

    我卻不會考慮到我帶來的影響。

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

    這就是經濟學裡所謂的公共問題,

  • and the problem of the commons is exactly

    公共問題恰好就是

  • what we face in the case of antibiotics as well:

    抗生素所面對的問題:

  • that we don't consider

    我們都不會考慮-

  • and we, including individuals, patients,

    包括個人、病患、

  • hospitals, entire health systems

    醫院、整個醫療體系-

  • do not consider the costs that they impose on others

    沒有仔細思考濫用抗生素

  • by the way antibiotics are actually used.

    會給別人帶來什麼影響。

  • Now, that's a problem that's similar

    這與我們所熟知的

  • to another area that we all know about,

    另一個領域的問題很類似,

  • which is of fuel use and energy,

    那就是燃油的使用和能源問題,

  • and of course energy use

    當然,能源的使用問題

  • both depletes energy as well as

    不僅消耗了大量資源

  • leads to local pollution and climate change.

    也造成了當地環境污染和氣候變化。

  • And typically, in the case of energy,

    特別是能源的使用,

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

    有兩個解決方案。

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

    一是更加有效率的使用現有的燃油,

  • and that's analogous to making better use

    同樣的,我們可以更好的方式使用

  • of existing antibiotics,

    現存的抗生素,

  • and we can do this in a number of ways

    我們可以通過很多途徑來實現它

  • that we'll talk about in a second,

    我們稍後再討論這個問題,

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

    另一個選擇就是繼續開採燃油,

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

    在抗生素的角度來說 就是尋找新的抗生素。

  • Now, these are not separate.

    這不是分開的兩個選擇。

  • They're related, because if we invest heavily

    它們是相關連的, 如果我們大量地投資

  • in new oil wells,

    在開採新的油井,

  • we reduce the incentives for conservation of oil

    我們對原油的節約意識也就降低了,

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

    抗生素也會發生同樣的事情。

  • The reverse is also going to happen, which is that

    相反的情況也會發生,

  • if we use our antibiotics appropriately,

    如果我們適當使用抗生素,

  • we don't necessarily have to make the investments

    我們就不必投資

  • in new drug development.

    開發新的抗生素。

  • And if you thought that these two were entirely,

    如果你認為這兩者

  • fully balanced between these two options,

    處在完美的平衡狀態,

  • you might consider the fact that

    那你應該知道

  • this is really a game that we're playing.

    其實這只是我們玩的一個遊戲。

  • The game is really one of coevolution,

    這個遊戲只是一種共同進化,

  • and coevolution is, in this particular picture,

    如圖所示,在獵豹和羚羊之間,

  • between cheetahs and gazelles.

    就存在著共同進化。

  • Cheetahs have evolved to run faster,

    獵豹進化讓自己跑得更快,

  • because if they didn't run faster,

    因為如果牠們跑得不快,

  • they wouldn't get any lunch.

    就吃不到午飯。

  • Gazelles have evolved to run faster because

    羚羊也進化跑得更快

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

    因為如果牠們跑不快, 就會被當作午餐,

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

    我們就在和細菌玩這個遊戲,

  • except we're not the cheetahs,

    但我們不是獵豹,

  • we're the gazelles,

    我們是羚羊,

  • and the bacteria would,

    而細菌,

  • just in the course of this little talk,

    就在我們說話的同時,

  • would have had kids and grandkids

    會一代一代地繁衍,

  • and figured out how to be resistant

    它們會想辦法抵抗抗生素,

  • just by selection and trial and error,

    通過選擇和試誤,

  • trying it over and over again.

    一再地嘗試。

  • Whereas how do we stay ahead of the bacteria?

    那我們要怎麼做 才能跑在細菌的前面呢?

  • We have drug discovery processes,

    我們有藥物研發過程,

  • screening molecules,

    篩選分子,

  • we have clinical trials,

    我們有臨床試驗,

  • and then, when we think we have a drug,

    當我們認為我們研發出新的藥物時,

  • then we have the FDA regulatory process.

    我們還要通過食品藥物管理局的審查。

  • And once we go through all of that,

    一旦我們完成了這些程序,

  • then we try to stay one step ahead

    我們又要再想辦法跑在

  • of the bacteria.

    細菌的前面。

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

    很明顯這不是一個 可以長期堅持的遊戲,

  • or one that we can win

    或是只依靠發現新藥物

  • by simply innovating to stay ahead.

    就能贏得勝利的遊戲。

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

    我們需要讓共同進化的腳步慢下來,

  • and there are ideas that we can borrow from energy

    能源問題的解決方法 我們可以引為借鏡,

  • that are helpful in thinking about

    我們可以嫁接

  • how we might want to do this in the case

    解決能源問題的辦法

  • of antibiotics as well.

    來解決抗生素的問題。

  • Now, if you think about how we deal with

    如果你們想想我們是

  • energy pricing, for instance,

    怎麼處理能源的價格,

  • we consider emissions taxes,

    我們會考慮污染排放稅,

  • which means we're imposing the costs of pollution

    意味著我們讓使用能源的人

  • on people who actually use that energy.

    出錢來解決排放的污染。

  • We might consider doing that for antibiotics as well,

    我們可以在抗生素上做同樣的事,

  • and perhaps that would make sure that antibiotics

    也許可以讓抗生素

  • actually get used appropriately.

    被適當的使用。

  • There are clean energy subsidies,

    還有清潔能源補貼,

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

    鼓勵使用低污染的能源,

  • or perhaps don't need fossil fuels.

    也許最後我們都不需要石油了。

  • Now, the analogy here is, perhaps we need

    同樣的,或許我們必需

  • to move away from using antibiotics,

    遠離抗生素,

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

    你仔細想想,什麼可以代替抗生素?

  • Well, turns out that anything that reduces

    一切可以減少抗生素使用的東西

  • the need for the antibiotic would really work,

    都是可行的,

  • so that could include improving hospital infection control

    包括提高醫院防治感染的能力,

  • or vaccinating people,

    給人們打疫苗,

  • particularly against the seasonal influenza.

    特別是抵抗季節性流感的疫苗。

  • And the seasonal flu is probably

    季節性流感很可能

  • the biggest driver of antibiotic use,

    是抗生素使用最多的地方,

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

    在我國和其他國家都是,

  • and that could really help.

    注射疫苗可以提供極大的幫助。

  • A third option might include something like tradeable permits.

    第三種選擇包括交易許可。

  • And these seem like faraway scenarios,

    這聽起來似乎和抗生素掛不上邊,

  • but if you consider the fact that we might not

    但是如果我們沒有足量抗生素

  • have antibiotics for many people who have infections,

    給被感染的人治療,

  • we might consider the fact that we might

    我們也許可考慮

  • want to allocate who actually gets to use

    把抗生素分配

  • some of these antibiotics over others,

    給最需要的人,

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

    但我們需要考慮臨床需要,

  • but also on the basis of pricing.

    以及定價的基礎。

  • And certainly consumer education works.

    當然教育消費者也可行。

  • Very often, people overuse antibiotics

    多數時候,大家濫用抗生素

  • or prescribe too much without necessarily

    或者醫生開了過量的抗生素,

  • knowing that they do so,

    卻不盡然明瞭自己已濫用或過量,

  • and feedback mechanisms

    而反饋機制讓他們知道情況

  • have been found to be useful,

    也被證明有效,

  • both on energy

    不僅在能源問題上-

  • When you tell someone that they're using

    當你告訴某人

  • a lot of energy during peak hour,

    他們在高峰期用了很多能源,

  • they tend to cut back,

    他們一般都會變得節約一些,

  • and the same sort of example has been performed

    同樣的例子

  • even in the case of antibiotics.

    在抗生素上也有所體現。

  • A hospital in St. Louis basically would put up

    聖路易斯的一家醫院

  • on a chart the names of surgeons

    把外科醫生的名字做成一張表,

  • in the ordering of how much antibiotics they'd used

    依上個月用了多少抗生素

  • in the previous month,

    來進行排名,

  • and this was purely an informational feedback,

    這全然是一個信息反饋,

  • there was no shaming,

    這張表沒有對醫生指責,

  • but essentially that provided some information back

    只是提供了一些資訊

  • to surgeons that maybe they could rethink

    這樣外科醫生可以反思

  • how they were using antibiotics.

    自己有沒有適當使用抗生素。

  • Now, there's a lot that can be done

    如今,在供給這方面

  • on the supply side as well.

    也有需要改善的地方。

  • If you look at the price of penicillin,

    如果你看看青黴素的價格,

  • the cost per day is about 10 cents.

    一天的價格是 10 美分 (三元台幣)。

  • It's a fairly cheap drug.

    這是非常便宜的藥。

  • If you take drugs that have been introduced since then

    如果你使用之後發明的藥物-

  • linezolid or daptomycin

    利奈唑胺或者達託黴素-

  • those are significantly more expensive,

    是要貴得多,

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

    如果你可以每天花 10 美分 使用抗生素,

  • the idea of paying 180 dollars per day

    那麼花 180 美元使用別的藥物

  • seems like a lot.

    看起來就貴多了。

  • But what is that really telling us?

    這個究竟告訴了我們什麼呢?

  • That price is telling us

    價格告訴我們

  • that we should no longer

    我們不應該

  • take cheap, effective antibiotics as a given

    在可見的未來裡