Learning that you have cancer can be terrifying, and every two seconds, somewhere in the world, another person gets the diagnosis. That's four people just since I started talking. But there are places where the fear of dying from cancer is amplified by an added treacherous risk that the cancer treatment will bring on a deadly infection from a killer superbug that even the most potent antibiotics available are powerless to team. It's called extreme drug resistance, and it can create a
devastating dilemma for some patients. The treatment for their tumors may kill them faster than the tumors themselves. Welcome to Prognosis, the podcast about health and science, medical technology, and the changes that are underway across the world. I'm your host, Michelle fay Cortes. This season, we're examining one of the dangers that keeps public health officials awake at night. It's been described as a silent tsunami of catastrophic proportions, one
of the gravest threats to human health. I'm talking about antimicrobial resistance, more commonly known as the irreversible rise of superbugs. The waning potency of critical antibiotics is happening faster than even the most dire forecasts. Tragically, cancer patients are at the front line of this global emergency. The conundrum is playing out sporadically in hospitals in many countries, portending a
global problem. One doctor in India is sounding the alarm even as he works tirelessly to arrest this unbolding crisis. Here's Bloomberg's Jason Gale with the story. Abdulgaf was raised in the off Indian state of Kerala, beside a river and rice fields that stretched as far as the eye could see. He'd often hold the hand of his grandfather, who was blind since early youth, and guide him along the narrow paths across the farm. School was in a
local village, wherefore was inspired to become a teacher. But he was emboldened to reach even higher by the Missile Man of India, A. P. J. Abdul Kalam, was a rocket scientist from humble beginnings who eventually became President of India. His example encouraged the young student to train instead to be a doctor. The meaning of the word doctor dosire, that is, to teach. A doctor is a teacher, not just a healer. I always wanted to become a teacher, and I became a doctor, so I am a teacher
and a doctor. To be a doctor is a normal profession. Patients come to you with their complaints, You examine them, You do the necessary investigations and find out what's wrong with them. You prescribe them medication and do the other necessary medical interventions. And you get a satisfaction when you treat patients because you're curing their ailments and as a human being, you're helping your fellow human beings. Dr G
four is now in his forties. He's an infectious diseases physician and clinical microbiologist in Chennai, the largest city in southern India. The satisfaction Dr Gefer said he gets from treating his patients well, it's fading. And the reason it's fading is because it's becoming harder to save his patients from diseases like cancer. And it's not the cancer itself that is becoming more and more of a threat to his patients. It's the infections that can come after chemotherapy.
Dr G four remembers one case not too long ago, at twenty year old college student with a cute my Lloyd leukemia is one of the worst type of cancer you can get, one of the worst type of blood cancer you'll get. Well, the treatment would give him more time. It's punishingly aggressive. The young man will be left with no immunity for weeks, leaving him vulnerable to infections, especially
from bacteria he's carrying inside him. God, they are expecting us to cure their cancer with chemotapi and a wonderful chemotherapy drugs, and then we explain into the family, yeah, your cancer will be controlled, but then you may die of infection. The outlook is grim either way. It's a choice between certain death from one threat and the possibility
of a faster death from another. The student undergoes chemotherapy, and the chemo, as expected, wipes out the white blood cells needed to defend against the bacteria entering his bloodstream. On one and you don't have immunity, And on the other hand, you've got billions or trillions of bacteria waiting to jump and jumping into your blood, but there's no defense. What will happen du antibiotic and if the even if you du antibiotic, the death rate is and has expected.
The bacteria get into the patient's blood. Dr Gofour tries to fight back. He knows the bacteria are resistant to the most potent antibiotic available, so he tries another colliston. It's a last resort option, and it subdues the infection, but barely. Dr GO four is still giving the same drug, and the infection is still lingering. And then it happens. A single bacterium undergoes a genetic mutation, giving it resistance
to that last resort antibiotic. It multiplies exponentially and it soon becomes the dominant strain, poisoning his bloodstream, and Dr G four is almost out of options. He has one last hope, a cocktail of antibiotics, ones that administered by themselves wouldn't work, but together could do something. This is a desperate attempt. We called combination therapy, combination of anti polytics.
And still the patient will die. The chance of the patient dying is more than eighty percent age in this scenario, and tragically, as expected, the young man dies. For me, it's become a daily issue. If you ask me the number of patients I've seen dying due to drugs infection, it's on a daily basis. So many of my patients cancer patients died due to drug resistance after chemotherapy. For me,
it's a day today scenario. Those multi drug resistant bacteria, those superbugs are proliferating globally on all consonants and in all countries. But in few places is the problem more worrisome than in India. Here, drug resistance has reached extreme levels. That's because of the massive use of antibiotics coupled with poor hygiene and sanitation. The devastating impact that's having on cancer patients has turned Dr go for into one of
India's fiercest crusaders on the subject. We are facing a difficult scenario to give chemotherapy and cure the cancer and get a drugs infection and the patient dying of infections. We don't know what to do. The world doesn't know what to do in the scenario. If you're talking about the post antibiotic era, you first see that in cancer patients. For cancer patients are the most vulnerable group of patients
you can ever come across in your clinical practice. Dr four posts regularly about their suffering on Twitter and LinkedIn. Discussing superbugs is a sensitive and politically charged subject in India. It risks casting a shadow over the country's medical tourism industry, which the Indian government predicts could bring in nine billion dollars a year by The superbl crisis is probably highest
in countries like India. The situation is getting worse, definitely getting worse because the drug resistants rate the superbug grade is increasing on a daily basis, so the number of patients dying are really high. Scientists have measured the burden of drug resistance in India in various ways. One has been to count the number of babies dying from sepsis as a result of a bacterial bloodstream infection not cued with antibiotics. An Indian new born dies every ten minutes.
That way, it works out to more than fifty eight thousand babies a year. No one is immune. In Dr Geffer's home state of Tamil Nadu. The former Chief Minister, a celebrated actress, died in late two thousand and sixteen from an unstoppable bloodstream infection. I work with cancer patients, a group of patients with the lowest level of immunity, and if you don't have antibiotics to treat infections in
cancer patients, you are in a very difficult scenario. Infection can be in the chest, it can be in the brain, It can be a demon, it can be urine, it can be blood. It can't be anywhere. And if you don't have antibiotics to treat disinfections, basically these patients die in front of your eyes. Around the world, at least seven hundred thousand people die annually from drug resistant infections.
That number will balloon to ten million deaths a year by twenty fifty and will cost the world more than one hundred trillion dollars in lost economic output without corrective actions. That's according to a review led by former Goldman Sachs economist Jim O'Neill three years ago. Lord O'Neill is the British economist who coined the term brick as a reference to Brazil, Russia, India and China. These rapidly emerging markets have become symbols of the shift in economic power towards
the developing world. As chairman of Goldman Sachs Asset Management Division, he oversaw more than eight hundred billion dollars of investments. In two thousand and fourteen, Then UK Prime Minister David Cameron asked him to focus on the anti microbial resistance crisis. Lord O'Neill knew little about the subject back then, but he had the finance acumen to demonstrate its significant and
to make the economic argument for tackling it. I recently caught up with him to ask Lord O'Neill about the findings of his two thousand and sixteen review and the impact it's had since its release. What we suggested is happening quicker than if anything then we could eventually happen. So I'm a surprise, not really because it's kind of what we said could happened, but it seems to be growing evidence that it's something quicker, and I think it's
a sign of the scale of the resistance problem. Lord O'Neill's review predicted that by fifty more people will die from superbug infections then from cancer and diabetes combined. Still none of that seems to be corralling the kind of action he and his team called for. Their recommendations were for forty two billion dollars to be spent over ten years to boost the supply of new medicines, vaccines, and diagnostic tools, and introduce mechanisms to reduce the demand for antibiotics.
What it really tells me is that no governments anywhere really wants to spend any money on particularly giving incentives to new use or drugs to be found and developed. I don't think they understand the urgency of it. Oh, it's clearly not a major priority. And I think a major dilemma of modern life is that in power al of this, governments don't like to spend money on prevention, and they end up spending more, rather wastefully, on response
to outbreak. And it's it's really quite stupid. Before the nineties, something as simple as a scratch need could turn into a festering sore that risk ending a fatal septic shop. Antibodics changed that and in just one generation added decades to average life expectancy. These literally laid the foundation for modern medicine. Surgery, organ transplants, chemotherapy, and c sections could be performed with a high degree of safety thanks to
the bacteria stopping ability of antibiotics. The life extending opportunities afforded by these wonder drugs have always been precarious. Almost as soon as scientists discovered ways to nuke bacteria with antibiotics, they were disappointed to learn bacteria could master ways to nuke antibiotics in return. For the past eighty years, humans and bacteria have been locked in a race for survival.
Between the nineteen fifties and seventies, a slew of new antibiotics port humans clearly ahead, but that lead is being lost in startling and horrifying ways. The development of new antibiotics is virtually dried up as drugmakers focused on more lucrative medicines, such as those for treating cancer, cardiovascular disease, and diabetes. Bacteria have seized the opportunity to exert one of their most powerful advantages over humans. Three and a
half billion years of evolution on this planet. It's allowed these microbes to amass a treasure trove of genetic tools to evade every kind of weapon thrown at them. And bacteria share their drug evating genes freely and easily with gems from the same and different species. These genes are often carried on the microbial equivalent of a thumb drive that enables one bacterium to quickly and efficiently pass, for example, the blueprint for nine different mechanisms of drug resistance to
another jam. These fortifying genes have spread like wildfire in response to antibiotics. We use and abuse these miracle cures on a daily basis. We take them when they're not needed, like for viral infections. We use them to fatten farm animals faster. We sprayed them on crops, and we dumped them in drains and rivers, contaminating the environment. All of that contributes to the rise and rise of disease, causing germs that are hard, expensive, and in some cases impossible
to treat. Dr go four spent five years training at London's Royal Free Hospital, an institution with a long history where thousands of cholera patients were treated in the early eight hundreds. He returned to India more than a decade ago. Back home, Dr go four was alarmed to find about one to two percent of infections among hospital patients were
caused by an extreme form of drug resistant bacteria. When it came back to India in two thousand eight, people like me and many many of us started talking about all the superbug crisis is going to happen. It's going to be a catastrophic crisis in a few years time. One of the reasons why Dr Gafford saw this superbug crisis unfold as quickly as it did. Has to do with how bacteria spread and how harmless chams can turn into untreatable pathogens. Species like E. Coal I and clepsy
yellow pneumonia carried in arogastro intestinal tracks. They aid digestion and vitamin production. These friendly bacteria are also in animals, and they're in fecal matter which we dispense, including the family dog. The bathroom is often the nexus. Each person sheds an estimated thirty trillion bacterial cells daily in their feces. Airborne germs known as toilet plume aerosols are created when
the bacteria are hit with a flash of water. Then they can land on surfaces, creating what the late Elma f in a micro biologists from Dartmouth Medical School described as a fickle veneer. In places where people defecate in their open and sewage isn't properly handled and treated, that veneer is more like a shag pile carpet, and it means fecal jams are readily ingested via contaminated food and water.
If you've had travelers diarrhea, it was most probably caused by equally a prime feckal Germ gross right, but it helps explain how the most resistant superbugs entered the public water supply in places like New Delhi, reside in the bodies of tens of millions of people, and have emerged as global public health enemy number one. If you're sanitation scenario is not good in the community, the superbug spread
in the water systems, superbug spread in the environment. Healthy people ingest eat the superbugs in the food and water. India's toil at shortage has contributed to a sanitation crisis that stoked the superbug crisis. Prime Minister Norander Emoti is trying to fix that with the largest toilet building spree in human history. Well, that's great news for public health and could eventually make a huge difference for now potentially
deadly gems continue to invade people's systems. There's an easy way to tell if someone is harboring drug resistant bacteria in their bow. You test their waste. Three years ago, Dr Gafour and colleagues collected a thousand stool samples from Healthy at All volunteers across three cities. They found one in every fifteen urban Indians carry in their intestines and shed in their stool common bacteria that are resistant to a class of last line antibiotics known as carbon pennam.
When doctors use a carbon penum, it typically means none of the standard therapy is work, and if superbugs that are resistant to carbon penems are spreading in the environment and contaminating food and water, it accelerates the loss of a critical treatment doctors like A four can use. Carbon is the most important antibiotic available in the clinical practice. We can call the extremely Druger system bacteria. They're not hospital but the god from the food and water they
consume every day. The bacteria like E. Colila are normal bacteria off your inderstine. If they get an opportunity to enter the blood, of course, then it's severe sepsist, severe infection. If you don't treat, you will die of these infections. But it's not just the food and water that's causing India's superbow crisis. India is the world's largest manufacturer and user of antibiotics for human health, and it's the fourth
biggest user in food producing animals. These drugs are easy to get, often obtainable without a prescription, and that means it's easy for bacteria to develop resistance. The problem in India is it's not regulated. That's Dr Bovner Syrie. She's worked in medical oncology in India and the UK for twenty five years. I first interviewed her in New Delhi for a story on superbugs a decade ago and we've kept in touch. So if I go up to a pharmacy, what if I even phone call a pharmacy, they will
deliver the antibiotics at home. And and that's a fact definitely in small towns, which is wrong. There should be some form of regulation for prescription of antibiotics. What the indiscriminate use of antibiotics does is it promotes antibiotic resistance. We know that Dr Syrilee isn't seeing in her practice the same levels of extreme drug resistance that Dr Gofour and other specialists around India have reported, but she's alert to the problem. In London, Dr SyRI we would consult
via Skype to reduce her patients travel costs. In India, she as this to minimize her patient's contact with health care facilities where superbugs are concentrated in sick patients and can spread because of inadequate cleaning and infection control practices. Antibiotic resistance is a huge concern for both oncologists and cancer patients worldwide, whether it's it's in uk or India. One of the commonest side effects of treatment is that
the patients are immuno compromised. Antibiotic resistance is a discussion that we have to have with all patients that are going to undergo immunosuppressive treatment. If a patient gets an infection with a multi drug resistant organism and we're not able to treat that infection, the cancer may be curable, but we lose the patient to the infection, which is unacceptable in this day and age. I think antibiotic resistance is a huge concern for all of us. Cancer treatment
breaches the body's natural defenses in multiple ways. For instance, the skin gets pierced when a needle is inserted for an intravenous infusion, but there's a critical vulnerability patient's face when they undergo chemotherapy. Those potent drugs target cells that grow in divide quickly as cancer cells do, but there's
often some collateral damage to healthy cells too. Hair can fall out, and the mucous membrane that lines the digestive tract from the mouth to the anus can effectively slough off injury to that protective barrier can enable bacteria from the gastro intestinal tract to enter the blood stream and cause an infection. Bloodstream infections are very common in cancer patients with low white blood cell levels when the culprit is a carbon PanAm resistant jam after two thirds of
patients die. One study found a New Delhi almost three quarters of patients with leukemia and other blood cancers. How are those dangerous bags? Here's dr Abduga for again. The death rate of patient with a carbon pon and resistant superbug and the blood is anywhere sixty to seventy percentage. So if I if I have a pay cancer chemotrapy patient with a carbon resistant superbul CPSLA in the blood, I can predict the chance of that patient dying is
sixty percentage or more. If that is also a colistint resistance, I can predict the chance of that patient is dying is eighty percentage or more. That means a patient is getting this infection is most likely these patients will die. And this has become a daily routine for people like me in countries with high superbul grades. We are literally living in post antibiotic era, especially in South Asia and militrding countries, and Dr gofour reminds us that creating awareness
and changing behavior is a mammoth task. India is a large country one point three billion population, seventy thousand hospitals, one million doctors, half a million pharmacies. Eight is a huge challenge. The present momentum is not enough. We need to really understand the magnitude of the challenge and find solution on the ground that's not really happening. Dr G four has spent years speaking about the issue. In two thousand and twelve, he convened a symposium that led to
a national road map to tackle the problem. Dr GO four was lauded internationally for taking positive action, but it put him in the crosshairs of some of India's health care businesses. Dr Go for himself works in a private hospital. Many of my friends in the healthcare industry have told me what you do is adversely affecting our business. This is my answer to them, No, I'm trying to protect our business because if people like me don't talk, policies
won't change. If our patients will die. How can we how can we sustain an industry so very, very very difficult scenario. The industry you are trying to protect sometimes blame you, and that's a real painful scenario people like me are facing. Dr Gerford told me there is progress, but it's slow. In July, the Indian government limited the use of Colliston. That drug of last resort was discovered in the nineteen fifties, but doctors quickly stopped using it
because of its toxic effects on the kidneys. While humans weren't using colliston, the drug was in popular use on poultry farms, where farmers fed its animals to stave off disease and hasten their growth. But the Ministry of Health and Family Welfare ordered us stop to that practice. The results of that policy are you to be seen, and maybe too late. Five years ago I visited one of
India's largest private ne andatal intensive care units. Colliston was the go to drug there for treating babies with sepsis because nothing else worked as well. Two years later, the same hospital had seen two cases of Colliston resistant infections. It's a tragedy familiar to Dr G four. I used to see patients quite sporadically. Maybe once in six months. Once a year, I get this kind of bacteria, but assistant. Everything that has changed. No, I treat a colistem resistant
infection once in two weeks. It's nothing unusual for me. So I can't remember the number of patients with the pand regorously infections I have treated. I treat dozens and dozens of patients with the panned regorously infections of my my career or the last few years. In the last few years, for Dr four, both his missions as a
teacher and a doctor have become harder. By speaking out about the crisis, his face criticism from within his own industry, and as a doctor, the spread of superbugs has meant his tools for treating his patients are deteriorating more and more. He sees cases like the young student he couldn't save,
and these cases weigh on him. It was actually a disappointment because as a doctor, as an infection specialist, living in twenty first century, with all the inventions and discoveries in modern medicine, especially oncology, I felt my hands are tied because I can't cure my patients infection. If I can cure my patients infection, however, wonderful the field of oncology is how about what about developments in the field
of oncology. They are not going to be useful because we know cancer patients die of infection, but there is still some hope. Aside from the government restricting the use of Colliston, there is one possible cocktail that could help in the fight against these extreme superbugs, an intravenous infusion of two antibiotics that fires the cells as Zafa sefter, in combination with another injectable antibiotic which Bristol Myers Squibs
sells as a zac dam. I asked a clinical microbiologist in Mumbai if that cocktail is something doctors are already using in India. It's being looked at, she said, but it's extremely expensive, about three hundred to four d dollars a day. That's roughly double what Indians earned per month on average. Government hospitals wouldn't be able to afford it, so patients would have to pay out of pocket and only the wealthy could pony up that kind of money.
There's another critical aspect to treating sepsis and cancer patients. Time doctors have a limited window, perhaps only eighteen hours to administer the right antibiotic once a patient develops fever to prevent a fatal bloodstream infection. That tends to make doctors are on the side of caution and to use the most powerful drugs available. You can't blame them. They want to save their patient's life. But it's also what's spurring the overuse of critically important antibiotics and driving the
superbiut crisis. And finally there's something else. We have no way of knowing how big this crisis really is. When a cancer patient dies from an infection, cancer not infection, will most likely be the primary diagnosis recorded on the death certificate, So the World Health Organization and its specialist arm, the International Agency for Research on Cancer, have no clue how many people die in this way. Doctors, like before
say the number is large and growing. The globalized nature of superbugs means cancer patients everywhere will eventually face this horrendous dilemma. And that's it for this week's prognosis. Thanks for listening. Do you have a story about healthcare in the US or around the world we want to hear from you. Find me on Twitter at a Cortes or send me an email m Cortez at Bloomberg dot net. If you were a fan of this episode, please take
a moment to rate and review us. It really helps new listeners find the show, and don't forget to subscribe. This episode was produced by Tobfheas. Our story editor was Rick Shine. Special thanks to ari Alstetter and Ruth Pollard who helped with the reporting, and Drew Armstrong. Our health care team leader, Francesca Leaves had a Bloomberg podcast. We'll be back next week with the new episode. See you then,