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(Please pardon this poor quality machine transcription while we work on the manual edit of this show)
I'm David Torcivia.
I'm Daniel Forkner.
[0:12] But if we learn from all this maybe we can start that the world might be broken but it doesn't have to be.
In 2017, England's chief medical officer Professor Davis said that antimicrobial resistance could spell the end of modern medicine. "We really are facing if we don't take action now a dreadful post-antibiotic Apocalypse." So antimicrobial resistance is something that we're going to be talking about today actually it's going to be about 90% of the show and we have some really excellent experts were going to be coming on to talk about some research that's going on right now and some perspectives from the field but we'll get to that in a little bit.
[0:54] Now why did Professor Davis say this well actually she said something similar in 2013. She said that the threat from infections was so serious that her government should add it to the National risk database of civil emergencies.
[1:10] And antibiotic resistance is a huge threat that has gotten much bigger over the past few decades.
[1:18] That is easy as nothing new when it comes to stressing human civilization. Some of the greatest catastrophes in human history have been because of disease things like the Black Blade which wiped out a huge portion of Europe's entire population or the 1918 flu pandemic which was worldwide cause global impacts.
[1:35] Unfortunately modern medicine and the invention of modern antimicrobials have prevented another pandemic from occurring in the past few decades. But that's beginning to change this is a problem right now.
[1:45] In India it's estimated that because of drug-resistant pathogens 60000 babies die every year.
[1:53] And worldwide the number of deaths that are caused from antimicrobial resistance is reaching over 700,000 people per year and that number is expected to increase dramatically as much as 10 million people like 2050.
[2:05] This threat is so high that in 2016 the United Nations. Convened a meeting with the general assembly and leaders around the world to discuss this issue as the first meeting of its kind and it got researchers and politicians all over the world scrambling to try and address this growing. Threat.
[2:24] But again it's not just antimicrobial resistance that were concerned about but the risk of infectious disease in general and there's a lot of components that go into that is very multi-faceted something that we're going to touch on when we talked.
[2:42] Course antimicrobial resistance is the ultimate factor and I want to come back to what Professor Davis said that this threat. Might dismantle modern medicine because what she said forced me to think about this issue in a way that I hadn't before the I thought that the threat of you know infection was just. If there's a super bug out there I might catch it and now I'm sick but it goes much further than that. Modern Medicine At Risk?
[3:08] Let me think we realize just how much we use antibacterials antimicrobial medicine. There's so many parts of our health system that involve antimicrobials so you go in for surgery or cancer treatment where maybe you're not sick from a viral or a bacterial infection but you going to be treated with antibacterials as part of this process because your body. Is vulnerable your immune system is compromised and it's that much easier to get sick so they prescribe these antimicrobials as part of a preventive process to keep you from getting even more ill will when you're in a vulnerable state.
[3:40] If we don't have effective antimicrobials in this process will then all these other side parts of the health system where we're not infected by a pathogen but are vulnerable. Well we can't treat people the same way that we have been and medical system falls apart of the whole.
[3:54] That's right it's not just people who coming to the hospital who are ill or their immune system is compromised that are at risk of antimicrobial resistant pathogens. But anybody who comes in to have a surgery for example now you're opened up your organs are exposed, a lot of major infections actually do occur in hospital setting as much as these doctors try to keep everything sterile bacteria gets in there. And so like you said and I. X is critical to these procedures that we take for granted now is just standard operations and Society C-section. Getting a transplant having knee surgery ACL MCL terezi's are very common in athletes. Treating diabetes all these things can become impossible if you cannot rely on antimicrobial medicine in order to prevent the spread of deadly infections.
[4:43] Not to mention is pathogens become more resistant to certain antimicrobials will we have to go to more exotic and more expensive options and that makes Healthcare as a whole more expensive as we all know health care costs are already spiraling out of control.
[4:55] Ballistics on a little bit of how this antimicrobial resistance comes about obviously we're going to talk about this throughout the show but on a basic level everyone has heard at this point that there is a problem of over-prescription when it comes to antibiotics.
[5:10] Sometimes doctors give them out to patients who have viral infections so it's really not a good treatment. People don't always take antibiotics for the full length that they're supposed to which can exacerbate this problem.
[5:22] Awesome people come in and request antibiotics when they have maybe just a regular cold that we in the password it ignored or they just not feeling well they come in they just prescribe me something and it contribute to this problem.
[5:34] And also industrial agriculture gets a lot of flack for their use of antibiotics in treating animals both for B deficiency which will talk about but also Mass medication for prevention that leads to some pretty serious problems.
[5:48] So over prescription can cause antimicrobial resistance but before we talk about how that comes about I want to highlight what an antibiotic is in the first place. What Is An Antibiotic?
[5:58] And they're really two main categories you have bacterial Seidel. And you have bacteriostatic these are the two broad categories of antibiotics and the first category bactericidal if they simply kill the bacteria. Just totally kills herself and the second type these bacteriostatic stay prevent in some way the cell from reproducing are growing. Under these two broad categories there are tons of different ways that antibiotics can Target a pathogen you know they can disrupt the cell membrane which causes cells to spill their guts the intake too much water and they explode. You can prevent the cell wall from forming you can prevent DNA and RNA from being synthesized there's tons of different things that you can do.
[6:39] What bacteria is really smart which is something we heard a lot from researchers and and medical experts when we were discussing this topic but at first feel sort of counterintuitive what does smart mean in this aspect I mean they're not going to be going out getting degrees in nuclear physics what they do. A Response To Attacks
[6:53] Don't underestimate the single cell.
[6:56] That's very true but what bacteria are so smart add is evolving and being very good at doing that very quickly.
[7:04] Two bacteria replicate at a fantastic rate at least compared to what we know as Cuban Twitter very long a reproductive process this happens very quickly and that means that we have Generations that can happen in just a matter of day many many generations. And what that means is that when you supply in evolutionary pressure to this bacteria in this case in our example as some sort of antimicrobial drug.
[7:26] Well because most of the cells and many times all the cells will happen to me as many generations when you have a mutation or something activates in the epigenetic code of these bacteria.
[7:35] Odds are it's it's nothing other you get something that is harmful to the the cell or actively kills herself but every now and then. Every thousands or tens of thousands or hundreds of thousands of generations you get a cell that happens to come across some sort of gene or Trigger or method of living its life that. Makes it resistant to disease antimicrobials and when that happens that means that sell that survive the onslaught of this drug is now the one that's reproducing. And that means the next time you apply this drug well it's not as effective because more more of these resistant pathogen are the ones that aren't making up the majority of this colony and it explodes from there.
[8:12] And so what surprising about that to me is like I said I came into this thinking there's a super bug out there that we've created by overprescribing antibiotics I might catch that. And therefore I get sick.
[8:25] But it's actually deeper than that is Wendy's bacterial cells develop genes that can resist certain antibiotics will those jeans can actually enter mixed with other species and get proliferated among. Many many different species of bacteria and David you right now could have bacteria in your gut. That has one of these genes or one of these mechanisms that makes it resistant to a certain antibiotic and right now that's not causing any problems because. Your body has these bacterial species under control but let's say you get a infection from something else maybe it's a viral infection your immune system is compromised. Or something just happened in your gut that allows this particular species to take over and you need treatment to suppress it. Now all of a sudden that treatment might not work so it's really a problem where this resistant gets into Global populations which then people can be exposed to under certain circumstances. And this resistance that you're talking about the way it comes about David it's why sometimes it's necessary for doctors to combine antibiotics into cocktails. So maybe the bacteria that you're targeting has been exposed to a lot of antibiotics that lets say Target the cell membrane.
[9:38] So the species has somehow developed a resistance. To this drug and maybe it does that by quickly synthesizing these proteins which can repair the cell membrane really quickly.
[9:49] Then maybe the de cocktail that the doctor uses in order to treat an infection by this bacteria in addition to targeting the cell membrane also targets the cells ability to create protein. And now because you're attacking the cell from a lot of different angles you're able to treat it.
[10:05] Until you mentioned that it can become more expensive to treat these infections that have resistance to drugs David.
[10:13] What we're seeing now and what is so alarming to epidemiologist and health officials all over the world. Drugs
[10:20] Is that Wendy's antibiotic stop working and you go to cocktails and you go to hire more powerful drugs are more expensive we've always been able to find a way to treat infections and treat disease for the most part. And if there is a particular species that's hard to come back we have drugs of Last Resort they just things like carpet Venoms and call the stanwich will get to in just a second but. What is so surprising is were now finding pathogens all over the world that are completely resistant to the drugs of Last Resort these are the ones that no matter what we come across an infection is pretty bad and our cocktails aren't working. This is our final weapon and it will always be this pathogen without even these are failing and we have no other options.
[11:06] And these types of threats aren't just limited to developing nations that don't have a built up Health infrastructure of countries like the United States.
[11:14] So here in the US in September of last year aluminum Nevada died.
[11:19] Incurable Infection incurable this is the first time that we've had this pop up since we have a antibiotics really. The researchers after this woman passed test of the Super Bug that has spread throughout her system and they found that it could fend off 26 different antibiotics. Quote it was tested against everything that's available in the United States and nothing was effective according to dr. Alexander Callen a medical officer of the CDC.
[11:43] And to be more specific this bacteria which normally causes urinary tract infections. Was sent to the CDC in Atlanta for testing and the doctors after studying its genetic makeup. Actually we don't have any drug in the United States that would have clear this infection you know those 26 different antibiotics that the doctors use will it didn't matter we had nothing in our Arsenal that would have been able to share this infection.
[12:09] And to highlight how this is a global problem this woman contracted this bacteria most likely from a trip to India. Where medical practices are little bit different and there have been more cases of bacteria that are multi resistant to drugs that we have available.
[12:26] And the global nature of this disease being picked up in India possibly brought you that I'd States and then who knows where from there that's really what setting us up for one of these. Risk Of Global Pandemic
[12:34] Global catastrophic pandemics and that's why things are different than they ever have before we've been able to manage this really well so far with our huge battery of antibacterials. We even had a pending on an enormous scale for almost a hundred years because of our access to this medicine.
[12:50] The risk of a pandemic breaking out.
[12:52] I've only gone up as we've become more interconnected globally and as the effectiveness of our standard medical practices Has Fallen. Some epidemiologists predict that an airborne disease could kill more than 30 million people in just a year and they claim that there is a high probability that this could happen in the next decade.
[13:14] And this isn't just a theory but this is happening all over the world right now.
[13:19] There has been an outbreak of Lassa fever in Nigeria this year it's unusual in a few ways so typically the fatality rate for Lassa fever is around 1%. But for Nigerians who are catching this that fatality rate is around 22% a tremendous death rate.
[13:36] And by the way the full name of this disease is loss of hemorrhagic fever and its worst case is very similar to Ebola and this means that you can be bleeding out of the mouth and your gastrointestinal tract.
[13:48] And the cause of this outbreak is not entirely clear yet it's possible that climate variability has led to an increase in a certain rat species that carries the virus or maybe the virus has simply evolved but. This highlights the need for better training and diagnostic equipment around the world which is something that will harp on later. And another virus case in March of this year Columbia had to experience the first case of measles now this is a particularly infectious and virulent virus it is estimated that one person could pass the infection on to.
[14:20] More individuals in an environment that's lacking vaccination. And it did this outbreak does seem to be a result of unvaccinated people particularly children coming to Columbia from neighboring countries. And there has been a lot of drama and political Fallout from the now retracted an inFamous Paper by Andrew Wakefield in 1998 that claimed a link between vaccines and autism. Some medical researchers claim the anti-vaccination conspiracy that resulted, set disease prevention back a decade or more and so it may be tempting to blame the individuals in this example for not being vaccinated and bringing the measles to Columbia, but this is more of a systemic issue in many Latin American countries there is a desperate lack of medical supplies and doctors.
[15:08] And so this may be a sign of things to come as many of these systemic issues that we talked about David. Dr increased conflict and refugees around the world this movement of people will open pathogens up to more opportunities.
[15:23] But it's not just a Jesus that we think of oh I have a cold. That are spreading like this but also sexually transmitted infections and he's are exploding across world with antimicrobial resistance.
[15:33] Risk traditional diseases that this is affecting things like syphilis or maybe you've heard recently of super gonorrhea a completely resistant form of Gonorrhea that is proving very difficult to treat and very easy to spread. As well as relatively new STIs like mycoplasma genitalium.
[15:48] By the way apologies to any scientist listening saying we're mispronouncing every single word this is going to happen most likely.
[15:58] But these diseases are exploding across the world spread through sexual contact. Syphilis was traditionally very easy to treat it's a course of penicillin then you're cured but now this very intense disease that serious effects on mental health and can ultimately cause death is now exploding in a way that we haven't seen ever. And this is also occurring a disease that we thought we had under control and that's HIV.
[16:20] Now we can think of HIV the single virus but really it's a collection of viruses that all cost similar symptoms must like the common cold and these viruses are constantly evolving with different strains flaring up causing problems and then being caught in controlled by researchers and doctors.
[16:34] But recent mutations improving much more difficult to control. When the place is this is occurring in Philippines infections in the Philippines have increased by 140% from 2010 to 2016 most of the new strains that are proven much more difficult to control with the drugs that we've created over the past few decades. Answer the question becomes how close are we to a global HIV pandemic once more because Beast rain so it's spreading out of the places that they're currently exploding.
[16:59] Viruses bacteria but also in sex. Are all developing resistance to the methods we employ to fight them.
[17:09] A new article that was published in the Journal of Entomology found that out of 48 states that were tested.
[17:16] 42 of them had lice populations that were completely 100%. Resistant to common over-the-counter drugs that Americans spend over $350 on per year to try and fight. Head lice that gets into children's hair and this is a new update from the study that was done in the past of found 25 States had populations of lice. That were resistant to these over the counter drug so this means that this resistance is spreading.
[17:45] But of course David it is a problem that so many diseases how many pathogens are becoming resistant to standard medication. But like we mentioned in in the beginning of the show the trend that is most alarming to health professionals around the world is the rise of antimicrobial resistant to these drugs of Last Resort. Most notably those class of drugs called carbapenems and the chemical call Austin. You would typically only give these drugs to a patient that has an infection that's so bad it's resisted everything else we've thrown at it this patient is at risk of dying and we have no alternative but to give them the most powerful drug that we know of. Drugs Of Last Resort
[18:22] But now even these drugs are becoming unreliable and once your last resort options are no longer available what do you do. This is a major concern because one of the genes that encode for colistin resistance in bacteria the mcr-1 gene we're not finding this all over the globe. And some recent research suggests that this Gene was really selected for on an industrial scale from pig farms in China around 2005 where it then spread to other parts of the world.
[18:51] And what's interesting David is the extent to which colistin resistance is a problem is not entirely well understood.
[18:59] It's difficult to study colistin resistant in clinical settings because like we said patients who need colistin are usually in such an extreme state of illness that doctors at throwing everything they have at the patient including colistin. To try and fight this infection which makes it really hard to isolate the effects of just one drug. And in a lab researchers have found the presence of hetero resistance in species of bacteria. So these are cells that appeared to be totally susceptible to medication on a genetic level but when exposed to the drug a subset of the population Will Survive and what this means is that you could diagnose an infection and based on the genetic makeup of the pathogen. You conclude that call Dustin in this case will wipe it out. But then you administer the medication and there's some epigenetic factor that gets triggered in a small group of these cells and now all of a sudden they can resist the antibiotic. Now there is still research needed an understanding how this resistance works for what we thought or Last Resort options.
[19:58] Okay it's that time the episode once more we need to take a step back.
[20:02] And we've been discussing a lot of antimicrobial resistance and he said things were still going to ditch Austin touch upon as we continue through but pandemics are very complicated and it's a multi-faceted problem with a lot of elements that goes into it into creating what becomes a global Health concern. A Multi-Faceted Problem
[20:16] And some of these researchers that we're about to talk to will highlight the interconnected nature of the environment. Animals humans in all these factors that play a multi-faceted role in our health system and the risk of the spread of infectious disease.
[20:32] Some of the factors that go into creating these problems in the first place and of course as always on the show let's start with the climate cuz this is big right now with climate change with all the effects that we're doing on the barman. Climate
[20:43] Directly in terms of logging on stress as well as indirectly from our contributions to anthropogenic warming well it all comes out to having potentially huge impact on the future health of all what are the great examples of these right now. Is an explosion in Lyme disease in the northern United States into Canada. The only in the last 10 to 15 years has it started becoming a problem in Canada.
[21:09] With warming Winters and longer summers allowing tick populations to slowly creeped North and as these deer ticks move farther north they carry with them Lyme disease.
[21:19] These cases have increased 600%. Since 2009 and what's funny is that historically Canadian doctors haven't studied Lyme disease it all intact I actually spoke with someone who got their medical degree in Canada who said when they were coming up they were told hate Canadians don't get Lyme disease. It just doesn't occur and so now it's kind of this interesting thing where a lot of the doctors feel, confused and I kind of caught between a rock and a hard place where patients will come to them and say I think I have Lyme disease I have all the symptoms I've looked it up on you know WebMD and it does appear that they have Lyme disease. But doctors aren't really equipped to diagnose the disease much less treated. And so it's created this money situation where some individuals have actually sent their blood to testing facilities in the United States spent thousands of dollars to get their blood tested, confirm that they do have Lyme disease so that they could then take that to the doctor and say look I have it now please treat me and I can take a long time and a lot of Heartache for some of these. People to get treated and similar situations will occur. Because of climate change as the temperature rises in certain places people will become more at risk for diseases that are traditionally thought of as Southern or tropical diseases things like.
[22:31] Malaria and if doctors are not prepared for them like this line case in Canada. Well if it's a more serious infection then the consequences of misdiagnosing someone of a more serious infection becomes fatal.
[22:43] But it's not just a matter of moving populations that is part of this problem.
[22:47] Stress on the environment directly also means stress on the animals that live there and when he's Wildlife populations start becoming stress whether it's because of lack of water whether the environments are shifting because of desertification or direct human impacts like logging on Forest. That allows that steady state of health in animals to break so this is the thing we talked about earlier where we all have bacteria living in us at all the time. And when we get stressed or our immune system is compromised that allows some of these potentially harmful bacteria. To really explode and illness that normally wouldn't be the case this happens in animals as well and populations of animals living in stress the varmints that stress them will these diseases can cause outbreaks in these local populations that can very easily.
[23:30] Two other species and ultimately to humans. Weather through contact with these animals do Airborne vectors or buy direct consumption of the animals in the food system but maybe the most horrifying threat here is I smell.
[23:44] In 2016. 20 people were infected and a child died from Anthrax exposure and it is assumed that this came about from permafrost that had thought from a heatwave and expose water sources to a deer carcass. That had been infected with anthrax. And because of this anti 6 Bossier to the water sources there were a couple thousand living Ranger that were then infected in this led to humans.
[24:11] They're great number of species that can survive for a long time in a frozen state.
[24:18] Scientist have revived Frozen bacteria as old as 8 million years.
[24:23] That were found in Antarctic Ice what scientists have also revived Frozen viruses as old as 30,000 years.
[24:30] So the concern becomes well if he's viruses if he's bacteria have been locked in the ice for tens of thousands or millions of years it's possible that are natural resistance in both humans and Wildlife during that time has disappeared. And these bugs for lack of a better word when they come back could cause huge explosions for population that just isn't prepared for.
[24:50] Much like happened with smallpox in North Central and South America as colonialist moved from Western Europe into the native populations.
[25:00] But they but when you say frozen ice this makes it seem like. Okay I just don't go to Antarctica or you know I don't take any polar trips but we're really talking about permafrost here these are areas like in Alaska the Tundra's of Canada and and Russia and Siberia. Places where you can actually settle and as the climate warms places that actually might become appealing for people to settle down and start building towns villages in Civilization.
[25:26] Especially as economic interest are moving in here like you point out and we start seeing things where we directly drill into this ground for what will exploration or mineral extraction this means going to be directly looking for these things spreading them in the population and bring us to.
[25:41] Two of these threats speaking of economic activity none or maybe more impactful on this topic then industrial agriculture. Industrial Agriculture And Food Animals
[25:49] Animal livestock poultry swine Missouri huge source of diseases that spread to humans so-called zoonotic diseases with 60% of the 400 emerging infectious diseases from animals like this.
[26:03] This is things like severe acute respiratory syndrome or maybe better known as sorry.
[26:08] And a big part of the way that these pathogens come about from the industrial practices associated with. Raising of the animals that we eat is the use of antibiotics.
[26:19] It is estimated that in the United States alone 70% of all the antibiotics that we use are given to animals. For the purpose of mass medicating them to help them grow faster of the new regulation has had an impact on that practice specifically but also they're given to these animals to try and prevent the outbreak of infections. And like we talked about that mcr-1 Gene that possibly came from pig farms in China as this resistance is encouraged in these animal populations these jeans intermix.
[26:54] Purses that we humans interact with.
[26:56] And of course that's 70% figure in the United States World globally half of all antibiotics administered go towards animals and although in the United States we're fighting the practice of using his antibiotics to promote growth.
[27:09] With things like the veterinary feed directive would pass last year.
[27:13] Exactly what a lot of countries don't have regulations like that and these drugs are given out in discriminately. In the UK this is a serious problem right now though researchers have found a large quantity of bacterial species in the chicken that is for sale in retail grocery stores. That are completely resistant to antibiotics which means that people are bringing home food and if they're not cooking it properly if they're not using good hygienic practices they are potentially exposed to this bacteria that is completely resistant to medication.
[27:44] But David I don't want to go too deep into this topic because we actually travel to the College of veterinary medicine at the University of Georgia to speak with researchers in this field of veterinary medicine, in each of these researchers are studying the role that antimicrobial resistance plays in animals and how that relates to human health. So let's let them shed light on this very important aspect of all of this. Interview: Dr Credille
[28:10] Over here with dr. Caddell he is a PhD in physiology and pharmacology who studies antimicrobial resistant in beef cattle as both the clinician and a researcher.
[28:20] He is a professor in beef production medicine and section head of field services at the University of Georgia welcome to ashes ashes dr. Perdue.
[28:28] Thank you for having me I'm glad to hear.
[28:30] Cute Elsa little bit about the work that you do and some of the research that you are pursuing.
[28:35] Yes happy to.
[28:36] Our research program right now currently focuses on the epidemiology and mechanisms of antimicrobial resistance in important bacteria associated with respiratory disease in beef cattle our goal is to.
[28:51] Really evaluate how our current animal use practices within certain populations of beef cattle contribute to resistance in bacteria that are important.
[29:01] Us and long-term helped develop more sustainable and microbial use practices that will I hope.
[29:08] Make the industry more favorable to the public and long term use of formation to improve cattle health and well-being come across North America.
[29:17] You mentioned making it more favorable in what ways has it not been favorable to the public.
[29:22] I think there was some perceptions from the public some right some wrong that current antimicrobial use practices in NY agriculture not just cannabis wine. Poultry Drive lot of resistance phenomenon that we see both in animals and people.
[29:36] Some of the things we do definitely contribute I think it's not you to say that we aren't a contributor to the problem but I don't think we were the whole of the problem so I think that the use of antimicrobials to promote growth to improve efficiency which is now a legal certainly.
[29:51] Average consumer who is removed from agriculture by several Generations looks of that doesn't pass the newspaper test it doesn't make sense to them that we would use a product in that way to make an animal grow more rapidly if it doesn't sound good.
[30:04] So one of the things that that we hope to do is really take a look at how what we're doing is contributing to the problem as a whole and how we can use information to really.
[30:13] Make sure that we're doing right by the animal but also right by the consumer because at the end of the day I'm there the one who's going to consume the product that we produce and we have to make sure it's safe and wholesome for them if we lose confidence.
[30:24] From the consumer the industries is not going to be there long term so.
[30:28] But maybe you can give us than just a brief overview right now what the current practice of antimicrobial techniques in raising cattle and Bovine and touching on swine even maybe.
[30:40] For a long time we used and microbials for different purposes we use them to promote growth and improve the efficiency we would use them to treat disease and we also use them to prevent and control disease.
[30:53] Can you qualify quickly.
[30:55] What is feed efficiency.
[30:56] We got what you mean by growth and feed efficiency.
[30:58] Right so up until January 1st of 2017 certain segments of the beef dairy in swine industry. Would include certain antimicrobials and why we don't necessarily understand exactly how this worked it actually the discovery of this was really a coincidence it there weren't weren't intended to figure this out but they would include certain microbials at.
[31:22] Certain levels in feed or water and we found that we included those in the ration in the water they rection more efficient and they would grow more rapidly.
[31:32] Betta fish in being the nutrition that they can send.
[31:35] Write for every pound of feed they consumed they would gain more weight than they would without that in there. Again as of January one of 2017 with the passage of The Vineyards be directed regulations that is now illegal no longer allowed in any. Segment of and wider culture So currently will use and Makoto's to treat animals with disease and to prevent and or control disease in animals that are at high risk of Contracting a certain disease.
[32:02] For the veterinary feed directive does it cover anything besides just Banning the use of antimicrobials for B deficiency what about prevention is well.
[32:11] 2 in addition to restricting the use of these drugs for the promotion of growth and feed efficiency what does in your feed directive also did is for a long time these products are available over-the-counter no Veterinary oversight was required.
[32:24] On the news feed directive had the effect of taking animico bills that. Were considered to be for various reasons important for human health had the effect of making them for lack of a better way to describe a prescription product.
[32:37] So the use of those products we're even for a treatment or control purpose prior to the vfd was it regulated.
[32:45] Do you think that's going to lead to a decrease in the use of drugs and preventing bacterial infection.
[32:50] It's a good question and the intuitive response would be to say Yes the real answer is we don't know yet.
[32:56] What we've seen locally in in in our general area is it certainly has contribute to a decrease in overall use one local feed mill in 2016. Used about 3,000 pounds of a drug called for tetracycline in the first 6 months of 2017 they only use 15 pounds.
[33:13] So a 99% decrease in in a year but that's one place so I can see what happened across the u.s.
[33:19] And then the question is is that entirely positive I mean maybe some of the use was good.
[33:24] It's certainly in in so if you look at what we saw in Denmark for example there were certain situations where once I was in the Cobras were removed the rates of certain diseases did increase so overall prescribing.
[33:37] It went down but not to the same level as they thought that would we saw more disease or require more treatment so we'll have to see.
[33:44] So it's sort of shifting from prevention to treatment.
[33:47] Right there there's this idea that even if it's for a disease prevention purpose it may be at a level that's enough to keep some subclinical disease at Bay and the I did we remove it that subclinical disease now rear head and you have more therapeutic use.
[34:01] Real quick can we just take one step back because you did mention that some people, too much blame on livestock practices for the rise of antibacterial resistance and pathogens can you just briefly go over how this microbial resistance in animals.
[34:18] Translate into a human problem.
[34:20] There are seven different ways of that might happen probably the most common the one we worry about the most would be that we have a consumer that purchases a product.
[34:29] Poultry pork ground beef whatever it may be.
[34:32] And that product is contaminated with some pathogenic bacteria salmonella would be one of the more important ones I'm campylobacter would be another.
[34:41] They would consume that product they would develop. Lira clinical signs be associated with infection with that bacteria and because bacteria are resistant we won't be able to treat them should an animal Coco be required that's probably the the biggest issue that we see another way that it can happen probably a bit less commonly contact.
[34:58] I'm you have an animal that is a carrier for some American Port bacteria you are in close contact with a dog cat or Scout or maybe.
[35:08] And contacted it just is transmitted to you and you pick it up.
[35:12] It's not just bacteria that we have a problem when it comes to resistance but you've also study the way viruses play a role in this right is there a difference in the way that bacteria and viruses develop resistance.
[35:25] Us restore disease in cattle which is my focus area viruses set the stage for the bacteria to cause clinical signs to the viruses often are.
[35:34] The primary problem but are treatment efforts within aimed at the bacteria the viruses by the time we see the animals are generally gone in the bacteria or what we left to deal with.
[35:43] So somehow the virus is opening the door for a larger bacteria how does that work.
[35:47] We see various different viruses that contribute to disease within different animal populations in cattle we see herpes viruses we see.
[35:56] And some cases we can see certain types of influenza virus is different what we seeing people but still in that same general family of influenza and what they do is they can damage the respiratory tract they can also suppress immune function. And by damaging the respiratory tract suppressing immune function and then allows bacteria which normally live in the airway.
[36:12] Low levels to increase in number elaborate toxins that cause disease.
[36:17] Okay so kind of bringing it back to that human from it's almost like we can have a small percentage of resistant bacteria in our system or in an animal system but.
[36:26] Because the immune system is functioning healthy it's suppressed and it's not causing a problem so it's only when you somehow allow that picture to expand now you have to deal with it but oh wait.
[36:37] It's resistant to our medication.
[36:39] Rescues for the economic angle of this so by producing this antimicrobial use in feed and making that feed less efficient. I guess that ultimately will have a numerical effect on how much that meatball or whatever other product looking at the cost because.
[36:56] And efficiency is there somebody who has look at that number and in nose with that actual effect is when it measures out.
[37:02] Do USDA prior to the veterinary feed directive regulations going into effect in January 2017 did some economic modeling.
[37:10] Using Data Drive from swine and poultry populations that they're there really wasn't a lot of information in Deer your beef cattle population so they had to extrapolate a little bit and yes there will be an increasing cost. That will ultimately passed to the consumer associated with the decrease in use.
[37:28] To be honest with you it's really silly miniscule it's relative to what it potentially could be.
[37:33] It's not quite what I thought it could have been the economic impact of it when these models came out and using the data that they had in my mind it was mine.
[37:43] So I guess that probably helped spur the the passing of this bill is Farmers and consumers will have to worry about as much of an economic consequence of this then it makes that trade off and saying will it protect the bees antimicrobials.
[37:56] Instead that much easier to do.
[37:58] These regulations really affected minority of cattle producers across.
[38:02] The US the average cattle producer here in the state of Georgia this is had very little impact on them and the good news is the people that weren't using these products to start with where they be a natural organic cream to Conventional form that just use them.
[38:15] There was actually economic benefit for them because they weren't using them from the start.
[38:21] You are today not very marginal increase in feed efficiency.
[38:26] And so for them they should theoretically be receiving the lack of a better way to say it a premium that at the end of the day would be back in their pocket so it was a boost for them in a way.
[38:40] Experience working with cattle.
[38:41] So I think that long-term our Focus has to become more the main focus.
[39:22] Temple Grandin has actually been here for the last two days and Temple is a fact remember Colorado State and is known for her expertise in livestock handling and Welfare and we've had some discussions I'm at the time that she's been here about what we call irice cattle.
[39:36] High-risk cattle are basically cabs that are taken from the cow on the farm sent to an auction Market somewhere nearby there commingled with cabs.
[40:40] Economically today they're going to spend more money but they're going to make more money to that's been one of the biggest challenges we face is that the economic incentives to do those things at least an hour.
[40:54] Types of cattle go through those sites programs they see the value in downtown the southeast we've got a ways to go but that's the challenge that we face but we have to use management and again we see.
[41:13] Reason vaccines Nutrition management we avoid these antimicrobials until we actually need.
[41:18] I know you mentioned prevention but does disease and someway play an important role is it good to have some level of disease in livestock populations in human populations is there any good that comes out of it.
[41:30] That is an interesting philosophical question you know it.
[41:47] And what they found was a vaccine that only protected 50% the population was actually worse than not vaccinating at all what would happen would be that if you don't vaccinate anybody the disease comes.
[42:13] Cuz of that the disease is able to spread more efficiently through the population so is some disease good for a productivity standpoint Montana.
[42:35] Muscle survive but they weigh less when they're weaned they don't perform as well as the cats didn't have disease so far my from a welfare perspective my productivity profectiv to me there's not a ton of benefit of having a low level of disease.
[42:48] Present because I think that even a low-level disease harms them away.
[42:58] Time we said no parasites don't we don't we don't want to see parasite within a population over starting to realize that animals.
[43:04] Al particularly horses to have evolved with parasites every time there may be.
[43:08] A level that's not harmful to the animal and a low level of parasitism a almost acting like a back seat again there's a point where successive but I did get a load of level.
[43:17] You don't have any problems and those animals would be animal that we could use through genetic selection say while these animals have lower.
[43:24] Pierside levels without any intervention this is an animal that I would select for over the long-term so I think it probably depends on the situation that you look at the disease that you look at as to how beneficial that maybe.
[43:34] In the face of what seems to be a rising risk of Texas disease worldwide are you an optimist you feel like we're making progress and responding to that or do you think there are a lot of challenges going forward.
[43:47] I definitely think that.
[44:06] So no I'm not I'm not missing I don't I don't think that things are as Bleak as some people might make them out to be.
[44:12] Like I saw Nash's ashes.
[44:14] The right people are here we have the right tools will developed right tools and I think long-term will be the place where we need to be.
[44:20] Any final comments you want to make.
[44:22] I think you hear different things about production and let her culture.
[44:25] And whether it be good or the bad I do think that I'm without Farmers whatever they may form crops animals both are good people.
[44:34] And I'm without them producing the products they produce this country wouldn't be where it is they definitely help feed this population the world's population and I think animal agriculture all in all central place to work with a lot of good people.
[44:47] I think the average person can really be comfortable in knowing that whatever they purchase beef poultry.
[44:54] Vegetables is safe we do a good job of making sure that the consumer is going to have something that is wholesome nutritious on their plate at the end of the day.
[45:01] But thank you thank you for being a.
[45:04] Thanks for having me I enjoyed being here.
[45:05] We are joined Now by dr. Catherine Logue & dr. Susan Sanchez. Interview: Dr Sanchez & Dr. Louge
[45:10] Dr Logue has a PHD in microbiology from the University of Ulster and she is Professor of population Health at the University of Georgia College of veterinary medicine. Dr Sanchez has a PHD in biology and clinical microbiology. She's professor and section had of microbiology and molecular biology at the College of veterinary medicine and she is assistant director and chair of one Health. At the biomedical and Health Sciences Institute dr. Lo can you tell us a bit about your background.
[45:40] So my area research has always been around Meats meat production animal health so if it's been slaughtered I probably seen it and I worked a lot of different areas yeah that's kind of weird to tell people but I seen it all so I worked in B5 worked in Cadillac.
[45:56] Poultry turkeys and chickens.
[45:58] What is your current focus of research.
[46:00] I'm looking at cellulitis in that turkey production and looking at the E.coli that cause disease and in birds like that and I've always been interested in out of microbial resistance of E coli we look at ecoli.
[46:12] Cause disease in poultry the same cut E coli strains that cause human urinary tract infection the same strains that cause neonatal meningitis E.coli in in newborns and then. My colleague looks at me from the path of Genesis point of view and I look at them from the. And microbial resistance what kind of resistance if they carry what kind of resistance is date they show up for things like that.
[46:31] Are you seeing that there's an increase in antimicrobial resistance with in animal populations.
[46:39] It's very hard to tell because there's always some level of the resistance there and some of its historical that exterior smart they pick up things and then they hold on to them we're seeing different kinds of resistance now that we would have seen maybe 10-15 years ago.
[46:53] What kind of resistance are you saying that's startling or surprising you.
[46:56] We're seeing a lot more strains that have multi drugs instead of just being resistant to one or two things we've got some strains that are resistant to a lot more. Sometimes depending on where the ice is said I said he come from they'll have like maybe even 10 resistances are some of the super ones and I have like maybe 15 resistances which is kind of scary.
[47:14] Exist out there and then we started looking for you heard of Colston The Last Resort.
[47:20] What I understand from call Dustin resistances that there's a particular Gene. That has been traced back to a pig farm in China is that right or is it more complicated than that.
[47:31] I think it's a little more complicated than that it's probably not just a single Farm it's probably what they think is in countries that use colistin as a supplement.
[47:40] That's where they sought emerge first and all of this started to break about 2 years ago and we have to start the collections around the world so we went and looked at ours. To see what we have and we found it in France from China and Egypt the same as other people that but we found him in disease-causing transit cause disease and poultry which is kind of a big deal.
[47:58] You mentioned Coulson uses supplement is that what are the drugs also used for p deficiency or is this just for treatment.
[48:04] I can't say for sure that that's what it was being used for I do know it was being used in certain parts of the world not everywhere different countries have different prescribing practices.
[48:12] I guess it changed pretty dramatically here in the US.
[48:14] Well you have never used it it's not being used here.
[48:17] I mean not just in terms of that but our entire pharmaceutical prescription with animals.
[48:22] Well the veterinary feed directive changed all that yes so now what they're saying is that if you're going to use a drug in production systems then you have to have a Veterinary sign off for it's all going to come under Veterinary oversight.
[48:33] Got to have a veterinarian that's going to prescribe it for you now everything's going to have to have a prescription you can have to have a reason for needing it so it's it's really all about good stewardship it's all about controlling it back down I mean there are farms that are still going to need something and this gives him to. At least the protection will why do you need this means you can't have a house of 10000 birds get sick you can't. Product like that into, shut the birds at 6 you got to have a way to treat them so now you going to work for the veterinarian and get a prescription when you need it.
[49:00] The new directive is fantastic if there's no more Farmers tweeting individually or going to the feed store and being able to buy antibiotic that's all.
[49:08] Dr Sanchez you are the chair of one Health at the University of Georgia can you tell us a little bit about what one Health is.
[49:16] It's a question that everybody ask is not at one type of research is an approach to.
[49:21] That we should not look at Health into silas's and do between medicine and probably help, help look at all of us involved.
[49:31] Of course in for certain areas the environment to so is that Nexus between all those three areas there is important to look at and do I dress him up your assistant one of the biggest examples.
[49:42] So every single component is involved environment is a reservoir for.
[49:47] Under microsystem bacteria doesn't matter when it comes from Lakes water feel that I'm being fertilized.
[49:53] And that's something that we shouldn't forget when we looking at is stewardship and the spread of an assistant to look up problems and I'm a girl.
[50:04] Prospective cuz if we try to tackle problems individually or an SI Lo we're not going to fix the problems we just going to make people some money get some rest.
[50:13] Paradinha the day we're not going to solve the problem.
[50:16] I suppose a lot of diseases are zoonotic and origin right there something 60% of emerging diseases I think are zoonotic.
[50:24] Probably about right now.
[50:26] Do either of you have a good example of a recent zoonotic transmission that our listeners would find interesting.
[50:32] So colistin resistance is a good example and it started out we started seeing these resistant bacteria what do they were salmonella or E coli in the production of animals. And then somehow that you started seeing the same thing and human populations so somehow or other it's matriculated or trickles to the system so probably Meats meat production. And now we're saying the same thing in humans so it's probably a good example and we've seen it not Justin. N e coli but you see the salmonella as well and plenty of other gram negatives so it's moving moving through the one that everybody's kind of freaking out about you see a lot of arguments but I was just thinking about that for example that was a big thing, ending of you going back to it even HIV it does not exist.
[51:15] The big bang that makes their own so neurotic but I think we're right now in the US.
[51:25] Just generally how have our practices contributed to antimicrobial resistance and maybe specifically colistin that we're dealing with right now is it something that has just naturally occurred or is there something in the way that we have been trying to prevent or treat.
[51:39] For infections that has lettuce to the situation now.
[51:43] Well if you think about animal production it's a lot more intensive than it was if you go back a hundred years so you got a lot more animals in a small area. And when those animals are together like that you're going to get things for somebody get sick and then a lot of lot of individual animals get sick and you know over the years I've had to find a way to treat this or control for them so that's not always been feed efficiency sometimes it's just matter treatment. And that's sort of how the cola something came about it's one of those drugs but that was working at certain parts of the world have used it not everywhere. I think the reason they didn't use it here in the states it's kind of an expensive rug I think there were a lot more cheaper alternatives like protected to hurt or whatever you had.
[52:21] The bacteria themselves or kind of smart bacteria find things. The genetics of a bacteria is always changing its influx so maybe along the way it bacteria developed a natural resistance to this and that's the next thing is it's like all this is kind of a great trait to have and then it passes it to generations and that it passes at the other books. So it's one of those things. I need my colleagues we've always kind of describes his back to your smart they pick up something and if it's in value that hold onto it if it's not worth it they get rid of it and call Justin was probably one of those things that they held onto and then when I started selecting for those bugs.
[52:56] And then if you selected for them where you go I don't think it's probably is it a miss you sore abuse thing I think it's it's just it just happens. And it just happened because they use that drug there, in certain parts of the world and maybe didn't use it somewhere else so it's just got moved around and you just you just send me see weave wave of it moves through it's It's Not Unusual let me look at how we do Commerce nowadays where where production moves through. I mean something on one side of the world can be sold on the other side of the world like a day or two days later than usual so that's how things move around.
[53:28] I don't always think it's abuse I think sometimes it's just the bacteria are evolving so fast I agree with you with your perspective on the transmission.
[53:38] Let me ask you this you mentioned things moving around really fast and you also mentioned Ebola that was a huge risk in the past and we saw.
[53:46] A small outbreak of Ebola and I think it was the Congo.
[53:49] Last year and recently it's been reported that the CDC is reducing epidemic prevention and 39 countries around the world this is because of epidemic prevention funding that is coming to a close and.
[54:03] One of the countries that were leaving is the Congo so the question is how important is it to.
[54:09] Monitor and track and treat these infections worldwide I mean do we in the United States have to worry about an infection halfway around the world is that anything that we need to be concerned about.
[54:18] Yes we should.
[54:20] Does the mission of the CDC is to protect its people at home and abroad and it's funny cuz I have to look this up last week for something else I was writing but having a presence elsewhere give you an idea what's going on it's like the next Stars. Don't you want to know what it is before it ever gets here so by having people on the ground there or people that see something like okay there's something new there something emerging. And that's what the CDC is always kind of dumb for that.
[54:44] You know you're prepared for it if it comes this way it's the same way with how we model the flu vaccines you know what strains are emerging and then once you know what's there than you you're ready for it when it when it does transfer to the side of the world.
[54:56] Usaid both of them have been doing a great job of preserving our borders by helping others be able to detect diseases and control them. So you guys better to control them out there that have to follow them inside when they come in so it is critical that we continue to have that funding.
[55:13] Since we're on the topic of borders and thank moving so I know dr. Sanchez you study tick borne illnesses at some point.
[55:20] And right now because of climate change some species of ticks are moving North that otherwise wouldn't have been and a lot of Canadian doctors are really confused right now because a lot of Canadians are being infected by Lyme disease and they don't know how to diagnose it.
[55:34] So I'm curious how do you see climate change and packing the risk of infectious disease going forward.
[55:41] Not just tick borne diseases but other diseases as well and I think is going to impact that is currently impacting.
[55:48] Difference of Microsoft we didn't have in the US but now he's moving up into Texas from Mexico. And we seen some some cases around here so it isn't a problem I need to going to continue to increase and we just have to. Turning our doctors in our button Ariens do I be able to recognize currently in the country but it could come.
[56:12] And Aaron be able to anticipate on diagnosis.
[56:15] You got to get the young veterinarians coming up they've got to be able to see these things I've got to be able to to relate it back I mean and then the same as positions they've got to be able to see it from the clinical side to human size. But that's all about the training and that's all about getting that material out there that they see them they learn and there's no better way to learn it then to see it when it happens.
[56:34] You're both mention that this is something that we just seeing is changes in antimicrobial resistance do you feel that antimicrobial resistance is outpacing our ability to treat them with antibiotics.
[56:47] Well you've heard the stories about how they develop a drug and then within a year or two that drugs no longer working the problem is the pipeline. And if you go back and look at the literature and what people are saying right now the big Farm industries can't develop these things fast enough. I mean that wasn't to take like a billion dollars to get a drugs developed and get it to work and get it to Market I mean it's that far down the line and drugs take lot more than 10 years to develop.
[57:12] I mean that's part of the challenge and then looking for alternative ways to find these drugs on these natural antimicrobial systems mean that's that's a lot of leg work ahead of time.
[57:21] Think about this for somebody like a big Pharma companies that's a lot of investment on that up front ends and then if not drug is going to be gone in 2 years are no longer effective.
[57:30] They can start all over again and there's less and less tour companies doing this now which is the sad part about it because it's it's so expensive to do.
[57:38] I'm actually at the end with antibiotics person get sick of course of antibiotics 3 5 7 days and they don't need them anymore there's not really that much return on investment for a big Pharma.
[57:50] Are there any vacations taking place.
[57:52] There is a lot of Investigation of Alternatives looking at the natural things again coming back to the natural oils. Cinnamon was out there at one point oregano I mean there's all these things that people willing to try to get them away from the drug they're even trying them in animal feed. The trick is to get the animal to eat it you know you can't put it into Hive that it taste the flavor because I'm almost refuse feed if it's if it's too strong but it's going down those Avenue. Other natural things that they can use on and there's a lot of Investigation into right now trying to find those alternative agents to take us away from just the Classic drug.
[58:26] And I think it was a big push on looking at to look into vaccines and I can we vaccinate for certain types of infections so we don't have to treat but the infection will be prevented.
[58:36] So but that's going in is infancy and I think we. Many of the new technologies within the sequencing and new research abilities that we have is very likely that we could develop vaccines for bacteria that are really effective.
[58:50] So viruses are very interested we talk to doctor could deal yesterday and he mentioned how in cows sometimes they just Harbor bacteria that has a certain resistance.
[58:59] Then an infection comes along from the virus and maybe they get respiratory infections and then all the sudden that bacteria because their immune system.
[59:07] Is depleted that bacteria without resistance is allowed to take over.
[59:11] Is that the risk in humans are we all are holding on to some bacteria may be in our God that's resistant and it just takes becoming sick.
[59:18] You've heard of questioning difficile. A lot of patients if they're in hospital for long periods of time will the suddenly develop a c difficile infection I mean humans naturally carry that in their gut when if you're treating them in the hospital and you give him antibiotics but good floor I get switched. You distract the floor so the minority species suddenly becomes the majority and it makes the patient sick and they've got ways to treat for that matter trying to control it. It's one of those things we do we do Harbor certain things that they still giving the right moment in time they will switch over and become the bad bug that you don't really want to think about. And be boys you have an upper respiratory infection and you have are bacteria that is resistant that colonizes Juno's in York but I do my end up with a secondary bacterial infection after your viral infection in the sinus infection for example. That is so it is very similar to what happened in. But I mean think about it it's just it is what it is and it's just sometimes certain things take over I mean we see it with. Poultry production we have E.coli. Can happily Harper DC call and then all of a sudden they call it just they call him the opportunist the low-level bug Sydney becomes the big opportunist and something sets at off whether it's ammonia levels in houses are weather at 7. Stress or heat or temperature or something happens and something flips and something changes and then it just goes.
[1:00:38] Looking at this from a systems perspective we did a show on wildfires in the risk of wildfires and we spoke to two firefighters from the u.s. forest service and.
[1:00:48] What we found is that it seems that in fighting every single fire in the United States and globally we actually.
[1:00:55] Paved the way for even at the risk of even greater fires in the future because some of these low intense fires that came through actually were healthy for Force kept them healthy prevented overgrowth so I guess what we're kind of curious about is.
[1:01:07] Is there an analogy answers.
[1:01:10] So that is there some level of disease that's good for us good for populations that maybe we shouldn't be trying to prevent if we're looking at this from a global life.
[1:01:18] Well when you were a kid did you get to go outside and you don't play in the mud and you know your mother wasn't worried about you.
[1:01:24] I did when I wasn't you know.
[1:01:25] And you weren't supposed to you know what when I was a kid you went out there and did stuff like that and you probably did pick up on God he knows what your mother just said you were fine for you in the bath and clean you up. I mean you have to challenge the system for healthy kids you got to challenge them you got to get exposed to things there's some things you probably don't want to expose them to. That's the nature but we should be able to do they give me a system has to be ready for challenges and the only way to do it is by turning it.
[1:01:51] Environmental organisms being able to print them off and stronger.
[1:01:56] Mom were talking about working towards preventing this antimicrobial resistance from becoming a problem for human health we talk about things like the vfd which passed last year I guess it's not entirely a animal antimicrobial problem.
[1:02:11] I need the number of factors that come into it.
[1:02:13] You got the human side of it too I mean they've been training younger physicians in training Physicians I always remember this but I was small at you don't need a pill for every ill. So I think promoting anime Kobe as soon as shipped on the health and human outside is a big deal to not every child to get sick needs a drug.
[1:02:30] Me sometimes it's a virus and you can't really give an antibiotic for a virus so there are things that have to run their course and I think, stewardship on the human medical side has really changed a lot too I think there's a realization that yet that's probably part of the problem and we can control it better by being more.
[1:02:46] Efficient and how they do things or don't just write a prescription get to the bottom of what's going on first.
[1:02:51] I'm going to be a little controversial I'm going to bring the societal aspect of things in the in our society these days a mother's work. Grandparents normally on or around so if a child gets an illness is imperative that a child has better I can get into daycare really quickly and there's an expectation in a need for this to have.
[1:03:10] In the past mom was around but you know they will be no problem.
[1:03:15] Because the child had time to recover.
[1:03:16] Yes I'm either going to have time now to him to take care of the kids at home and spend 3-4 days taking them through a viral infection course.
[1:03:25] The kids need to go to daycare and the only way to do go to daycare they are on antibiotics so is it holds Society.
[1:03:37] Quote on quote at that is promoting these need from the parents to get antibiotics and enforces the doctors to try to give it to them to make them happy.
[1:03:45] So a good stewardship better training and the ability for mothers to be able to stay home or dads for that matter.
[1:03:52] I wouldn't have a society that is very go Healthcare this very confused.
[1:03:56] Also doctors are pressured to get patients in and out as quickly as possible.
[1:03:59] Absolutely yeah.
[1:04:01] And that can also mean there's not enough time to sit there and accurately.
[1:04:05] Address all the concerns it's easier just to write a prescription especially when you have pressures from pharmaceutical Industries to do just that and so you're balancing these economic incentives with the health incentives and stewardship of global Health at the same time.
[1:04:17] Very true.
[1:04:18] So is there beyond the stewardship things you mentioned is here and need for a regulatory framework horse is something that civilians people who aren't in the health industry just need to be more.
[1:04:27] Aware of or like one Health would suggest is a multifaceted problem that needs lots of solutions for many angles.
[1:04:34] I think it is multifaceted I think I've heard this before from the drug company side that it takes so long to get something through and get it approved and Regulatory you know the pressures to try and ease that bottle neck up and that'll help.
[1:04:46] There needs to be a lot more investment because clearly we're going to keep running out of drugs at the rate we're going there's less and less number of companies that want to do or MD on the stuff now. So we're not going to have them on the other end if we don't start at the farm at and or the investigative and be able to come up with candidates. I mean we have to come up with candidates and then test them and see if they work and then move them through the system so there's many aspects that needs work.
[1:05:10] Investigating Alternatives investigating vaccines that's a great alternative we can go up there so there's no drug at the vaccine instead and finding ways to develop all that. Finding ways to create those Partnerships between the industry side of things on the academic side you know where some of the research can be done and then creating those good collaborations will help with the law. And basically all of that it requires finding and even negative stewardship program Brook corresponding Hospital implement. Stewardship programs and then compare that is to worship with other hospitals and I have Regional and National stewardships and awards for those people that I tell you. Montane senior high standards in a level surface to worship but if that's going to cost the money who's going to pay for that insurance is I'm not going to pay so where is the money come from.
[1:05:55] We need more funding I know Larry is the wind is more otherwise been going to win it.
[1:06:00] And speaking about just Health in General on you mentioned doctor Logue how this bacteria is able to spread a lot easier when you have a lot of cattle together.
[1:06:09] Intensive agriculture.
[1:06:11] And maybe there's just a better way of doing industrial practices where it's not so concentrated and and not so compartmentalize and.
[1:06:19] But again their economic centers that play it right.
[1:06:21] Well there is and then you've also got to think of how many people you got to feed considering the world populations going to be seven and a half billion and everybody needs to be fed it's come down to two doing this at higher populations in smaller areas and we have no choice. If we go back to the grazing Landscapes when I can be able to produce enough that's sad part about it how else can we doing meal worms.
[1:06:49] Willy's Jeep restoration.
[1:06:54] Banquet dinner is singing chick but we really have to come up with ways of be able to do more intensive farming or without the risk of endemic river systems were the rest and we need to be able to control the Wii. Run into these intensive farming really not know he was going to happen and then I know this is what happens with that weird in the in the process of hopefully understanding of fixing it and by how many million will be there 10 billion.
[1:07:21] Are you optimistic about the state of infectious disease going forward you think we're on the right track or is there many obstacles ahead.
[1:07:30] I think we're on the right track I think the veterinary feed directive gives a good place to go I think stewardship is gotten better. I think the next generation of doctors and veterinarians coming up will look at this differently I think they'll be much more than you know restrictive and ask the questions I think any of that generation will ask a lot more.
[1:07:47] He's going to take a lot more orandi over time we can we're going to need a lot more and there's a lot more Innovation out there we just need to tap into it I think there's somebody out there right now.
[1:07:56] That 12 year old or 10 year old is wondering on here today and it's probably already thinking about it then that's the next generation is just bringing them up and getting them going.
[1:08:04] So we need the right infrastructure to help the young minds to be able to achieve what they need to achieve their you going to save us there more money for before.
[1:08:13] Education and Research.
[1:08:15] If either of you have specific comments you want to add to this or organizations you think I'm doing the right thing that you'd really like to plug with or let listeners know about.
[1:08:23] Fda's in a really good job of kind of keep track of things to CDC does Brakes in the human health side.
[1:08:29] You know we talked before about how the funding is changing and that's going to be a big change in what happens during its I'm sad to see that.
[1:08:35] Maybe we can train those individuals another country before the CDC pulls bike have have a team they are in place and. You know be able to work with amazing from a distance I would like to get from some cuties to CDC and USDA they actually over there to individual Silas. They actually have offices in each other's institutions and I don't want Health officer in the have delegates USA people are on the CDC and so they're really trying other the structure of the government in Spain.
[1:09:03] Slow but steady progress.
[1:09:04] And I think you know you'll see that as Generations come through the younger scientist coming through with work in a different manner I mean it's all there it's just it's just creating those collaborations and building those bridges and keeping those bridges up the days of the single research that knows everything. Is exactly I mean we all work together now I've been on email this morning with a guy in Florida who's a who's a pediatrician.
[1:09:26] So we we finding ways to do things together we're fighting ways that are common between us all we want to look at the same things he's looking at it for the human health side I'm looking at it from the bacteria side. We can do that but you got to be willing to do that step forward Step Up make those bridges make those connections think outside the box.
[1:09:43] And also maintaining that open access to the research that you put out so that people who aren't in these institutions like this position have access to that can reach out to you about the things.
[1:09:52] Absolutely absolutely I mean he reaches to us we reach to him and we found things that are common between both of us.
[1:09:59] Open Access Publications is very very important issue but I think we are taking the right steps right now I could get better she get better but it's going to take a little bit of time from everybody but it's a good way to go.
[1:10:11] Something were going to discuss in detail in the future episode so maybe we'll be back asking you questions about that.
[1:10:16] Thank you so much dr. love thank you dr. Sanchez for joining us we really appreciate your perspective.
[1:10:24] Good to Jesse thank you very much.
[1:10:25] Thank you to both of you thanks so much. China
[1:10:28] What are things I thought was really interesting to your Daniel was the mention that they had looking for someone natural solutions to these problems and for me what was so funny about that was you mentioned earlier that Chinese is a huge portion of the world antibiotics.
[1:10:41] Well that's right David Chinese doctors prescribe for roughly 10 times the antibiotic dosage that American doctors do. I know you do they use about 50% of the world's antibiotics each year despite the fact that they're home to 18% of the world's population a huge number no doubt but still a greater proportion of antibiotics than any other country in the world.
[1:11:02] Written in the west at least we have his perception that Eastern medical practices are very traditional and natural. But I sort of funny to me to listen to this where we have these Western researchers, talking about things like cinnamon as a potential antibacterial while China is going crazy prescribing the antibacterials that maybe we would consider more traditionally Western type of medicine. But it's encouraging that we are looking at these natural alternatives to this very industrial process which in and of itself they're the production of these drugs has severe impact on the creation of these antimicrobial resistance.
[1:11:36] Dr. Sanchez spoke about one Health and how the health of all of this is interconnected the health of the environment the health of our animals and our human. And all of these researchers that we talked to did point out that we can't put all the blame for the risk of infectious disease on animal medicine. That's why I do actually want to focus real quick on the environmental component because it's not something that we've touched on in great that's yet. Environment
[1:12:00] And that's that there's a huge share of microbials and the environment as you would expect in a lot of them have natural resistance to certain things. Like are pesticides and herbicides because of all the inputs that were putting into the environment a lot of resistance is developing and has develop naturally. In species in our environments and a lot of these species are not harmful to humans and the more resistance there is in the environment the more that these genes that encode for that resistance can pass to other species. And become part of the species that can impact humans and there are countless examples of Industries. That pollute the environment and the degree to which this can encourage this resistance is a shocking Discovery particularly in India scientist studying the waste that's being put out by pharmaceutical companies in India. Found in 2006 that companies were dumping enormous volumes of antibiotics directly into rivers and antibiotics were concentrated. 31000 times higher than what you would expect from a typical sewage sample in other parts of the world. And of course they were finding bacterial species in the environment that were highly resistant to antibiotics including bacteria that causes infections in humans.
[1:13:11] And since then India has put regulation in place to try and prevent pharmaceutical companies from getting away with direct liquid waste pollution.
[1:13:20] Antibiotics are still allowed in Wastewater and there are high levels that are still being found in the environment.
[1:13:27] And what was his a huge problem in India that like we mentioned earlier can have Direct effects on human health with that super bug that caused a fatality in Nevada last year. This happens everywhere antibiotics Leach from Farms from sewage I mean if your on the bacterial course and you go to the bathroom while you're putting antibiotics directly into the sewage system. And many other means are all born into the environment and also two different ways. In the UK environment tool samples often times have higher antibiotic concentrations been in patient being administered antibiotics.
[1:13:58] In the study that actually discovered that fact David was research that was aimed at determining the level of antimicrobial resistant species and Surfers in the UK.
[1:14:14] Existence species in their bodies these superbugs then just your average person who doesn't serve.
[1:14:20] And this is mostly because the servers are swallowing lots of sea water more than 10 times what other swimmers are. And we'll sort of a disgusting fact but that seawater even despite lots of efforts to clean it up well it's carrying a lot of sewage runoff and I kept in the body carrying with it all this antimicrobial resistant bacteria.
[1:14:40] Speaking of the environment and the health of the environment there is a particular parasite called a hookworm that thrives in poor environments. Socio-Economic
[1:14:49] Literally economic for places but also poor in terms of their open sewage systems it's generally thought of a parasite of poverty because. They usually enters the body through people's feet as they walk around open sewage environment and it can cause serious effects in people including iron deficiency. Weight loss tiredness anemia and even decrease cognitive function especially in children. And this was a problem that we had in the United States, it was actually pretty rampant in the Southern United States in the early 1900s as we expanded our population but we didn't have the infrastructure and sewage system in place that we have now in this parasite went away in the 1980s.
[1:15:34] But now researchers have found. An outbreak of this parasite in a particular place in this world that has not caught up in terms of its sewage infrastructure and people are being impacted by an infection that you would typically associated with areas that lack development, no David where would you think that this might be occurring.
[1:15:52] Well I can sense the setup when I see one up and I I really feel like you're leading me on here so I'm going to guess something that maybe isn't so obvious.
[1:16:01] I think about it it's a parasite that thrives on poverty thrives on open sewage in it so it would be a place that has poor infrastructure.
[1:16:08] Okay okay well we we.
[1:16:12] There's a lot of options that you have here.
[1:16:14] But we were just a riffing on you literally swallowing sea water sewage so I'm going to maybe guess for the UK because they're also circling the toilet of declining quality of life like the us we are here so you can that's my final answer.
[1:16:29] Remember this is infection of poverty open sewage.
[1:16:30] I know what I said brexit baby let's go.
[1:16:32] Well it's not that UK it's the United States.
[1:16:35] As my second.
[1:16:37] Yeah it's the United States the same place that we thought this parasite I disappeared in the 1980s well it's back the reason its back is because.
[1:16:45] Like we discussed in our declining after structure well that collapses real health effects and one of those is hookworm.
[1:16:52] Right one and three people that were tested in a county in Alabama tested positive for hookworm in fact 73% of the people living in this area. Were exposed to raw sewage it's just a problem there and the residents don't have the money to put this infrastructure in place. As we talked about in our infrastructure episode a lot of municipalities don't want to spend the money on infrastructure so what they've opted to do instead is start fining people for not putting in place their own septic sewage systems or their own piping systems in fact, one woman was jailed for failing to purchase.
[1:17:28] A septic system even though the cost of that system was greater than her total annual income.
[1:17:36] And this is part of the reason why the UN was recently touring the United States in particular the South to examine the level of poverty and the final report said that it was something they had never seen in a quote developed country.
[1:17:48] We can talk about that issue particularly in a different episode David it's a serious concern and something that's not getting a lot of attention surprisingly you would think that if an area in the United States is experiencing raw open sewage that's resulting in a, kind of infection that we were supposed to have gotten rid of that this would be big news but it's not because it's affecting people in poverty and not other people but.
[1:18:11] Again that's something we can talk about later.
[1:18:13] Maybe part of the reason why this hookworm isn't getting the attention it deserves it because there are bigger health problems elsewhere. Global Prevention
Barack Obama: [1:18:19] Thank you for bringing us together today to address an urgent threat the Ebola virus is spreading at alarming speed if unchecked this epidemic could kill.
[1:18:30] Hundreds of thousands of people in the coming months.
[1:18:33] If ever there were a public health emergency deserving an urgent strong and coordinated International response this is it.
[1:18:42] But this is also more than help price is a growing threat to Regional and Global Security Public Health Systems at collapsed right now patients are being left to die in the streets because there's nowhere to put them.
[1:18:55] Economic growth is slowing dramatically and in an area where regional prices can quickly become Global threats stopping Ebola is in the interest of all of us wages men and women fighting on the front lines.
[1:19:08] Of this disease have told us what they need they need more beds they need more supplies they need more health workers and they need all of this as fast as possible.
[1:19:17] What are the donations have to do more to prevent detect and respond a future biological threats before they erupt into full-blown crisis.
[1:19:25] This is President Barack Obama speaking in 2014. And his special assistant and senior director for development and democracy Gail Smith set of the time quote this Ebola epidemic is the most start notification the world has been given. That all of us are vulnerable if all of us are not prepared as though they were of course responding to the threat of a global Ebola pandemic.
[1:19:51] And it set off a huge injection of funding to the CDC for disease prevention about six hundred million dollars was given to the CDC to help identify track and prevent the spread of infectious disease around the world.
[1:20:05] Well that's five your funding is now coming to a close and it does not appear that the CDC is going to get additional funding for disease prevention and as a result ization is leaving.
[1:20:23] Huge deal with it goes back to what doctor Logue says is that if we're going to protect people in our own country. We have to have a present around the world to prevent the spread of these diseases because the world is so interconnected someone that experiences an infection in one country can easily lead back to us. Do a variety of different ways and it's interesting that were specifically leaving the Congo I mean this is just a great example of why this is a problem because last year there was another Ebola breakout. That occurred in the Congo in 2017 and it was contained relatively quickly because there was a presence of medical facilities and specialist who could quickly identify what it was. Where it came from and how to prevent it from spreading. What these are the types of things that we need and that we're getting rid of because of this lack of funding being able to respond quickly when these outbreaks occur can be the difference between something that's very isolated.
[1:21:18] And a global pandemic.
[1:21:20] Again the CDC the Centers for Disease control's full name is the Centers for Disease Control and prevention. And that second part is so important something we've lost over even in the acronym that we use or the CDC and in the time of this increasing risk of pandemic because if he's Global factors we've mentioned as well as antimicrobial resistance will the funding for this organization continues to be cut. When we need it more than ever.
[1:21:44] And when it comes to Global prevention of infectious disease one of the vital components of that prevention is disease surveillance. Disease Surveillance
[1:21:52] This is one of the only times you'll ever hear is in this show saying okay surveillance here is good and an important thing that we need to be investing more money and you'll probably never hear me say those words again but we are right now.
[1:22:05] That was actually a little uncomfortable riding out the importance of surveillance but disease surveillance is a very important component of responding to in preventing. The spread of disease worldwide and it involves identifying new outbreaks tracking their spread and predicting where they might go another where would you expect the information on tracking disease to come from let me what would be your guts reaction.
[1:22:28] Probably that to fold thing so one government organizations like the CDC looking into all this and then maybe some sort of reporting body from hospitals. Collecting this information on disease that comes in and sending it off to an organization like the CDC be my guess anyway.
[1:22:46] It's not a bad gas and a lot of important information does come from hospitals and doctors offices and other medically related places when it comes to tracking disease but that's not nearly enough in one thing you might, surprised to find out is that local newspapers and social media these are called Advent base surveillance will they're actually very very important. And as an example the 2003 SARS outbreak which started and China was identified by the World Health Organization months before China officially announced anything was going on. And the who was able to pick up on this so quickly because of local news reports and social media rumors. But they analyzed another example in 2009 the fact that the H1 N1 influenza virus was spreading was determined by looking at local reports coming out of Mexico.
[1:23:36] But right now the consolidation of local newspapers has started creating a crisis for disease surveillance mostly here at home in the United States.
[1:23:45] Aziz Municipal papers either go out of business or bought up or merge with larger Statewide or maybe major city newspapers local municipalities are losing coverage.
[1:23:55] Reports from small towns from places that would normally have this information track Twisted upload it online and made easy for researchers to collect this and analyze Trends in health. That resources increasingly gone as Focus Shift to the Statewide and major city Focus because of profitability concerns.
[1:24:12] Answer that consolidation is a major threat to our ability to track the spread.
[1:24:17] Of infectious disease and also pinpoint where they start from but it's not just spreading disease where this is impacted but also research there was a computational epidemiologist from MIT in Boston Children's Hospital. Who published a paper in 2017 related to the outbreak of the mumps virus in the state of Arkansas and the models in that paper that try to explain why so many children were being infected.
[1:24:43] By the mumps virus relied significantly on a local newspaper for context for some of that information coming out of Hospital.
[1:24:51] It's pronounce Arkansas.
[1:24:55] Evidence that there's a really interesting history there about the pronunciation of the state originally was Arkansas and then this like crazy guy wanted to pronounce Arkansas and he like bought all the newspapers up and kept telling everyone it's been on Arkansas and eventually it was.
[1:25:09] So there's a lot of negative things can happen when newspapers get Consolidated we lose the history and the.
[1:25:16] I mean is not entirely true but that's that's the tldr version of what happened there did you ever wonder why it's pronounce Arkansas.
[1:25:25] I don't know David this sounds like another conspiracy within a conspiracy and frankly a little bit of fake news.
[1:25:31] But all these things that we talked about David the spread of antimicrobial resistance the way we are impacting the health of the environment the health of our animals the risk of pandemics all of this as you would expect.
[1:25:45] Has a direct economic cost.
[1:25:48] You know I feel honestly little bit silly even having this this section of the show in here.
[1:25:53] You feel silly about whatever it is you're about to talk about that you don't feel silly about the pronunciation of Arkansas.
[1:25:59] With Arkansas I'll die for that I'm going to go ahead and point these numbers out just because they are staggering and they're interesting but. Economic Cost
[1:26:07] I need this this show ultimately we're discussing lies and discussing Millions tens of millions and potentially even more than that lives lost because of these problems because of microbial resistance and to have to sit down and in turn this into. Equations of lost wages. Or or loss growth potential does a really terrible job of extolling the loss of human life of humanity that this discussion actually is about. The efforts to quantify all the suffering and turn it into a stat that you can breed in front of banks or politicians should get them to recognize how much of a problem this has on their bottom line that's sort of sick but anyway that's getting into another conversation the Social Security. A report commissioned by the British government and published in May of 2016 tried to calculate this and see what Global Production losses would be if we were. Focusing on Curbing this antimicrobial resistance and that number came to 100 trillion dollars at trillion with a t by 2050. If we don't make these efforts right now that's massive and most of that occurs in low-income countries they could lose more than 5% of their GDP by 2050. And this is during a time when these developing countries are supposed to be exploding in GDP growth not losing it. The world Vine with exports could shrink up to 3.8% by 2050 again we depend on This Global growth or discussing because of this antimicrobial resistance a world where that is shrinking.
[1:27:31] Global increases in healthcare cost me range from 300 billion dollars more than 1 trillion with a t per year. By 2050 and it's also cut into livestock production which could decline from 2.6 to 7.5% per year.
[1:27:45] Which would be terrible Ford attrition for protein but actually might have a positive effect on the environment but maybe that's the conversation again for another time. And as these problems get worse well drug cause you're going to go up. And is the cost of using these drugs go up and make their health care more expensive and even more as these simple antibiotics that were currently using these first defenses well as they become more and more useless with develop more antibiotics to make up for them. And these antibiotics cost a lot of money to develop in the billions of dollars and then they're effective only for a couple of years. And that just doesn't make economical sense for these pharmaceutical companies to produce them to put that much money into the production of a drug they don't even know if it'll exist and be useful for long period of time so we're seeing less and less investment in this area when we need it now more than ever. This is one of those negative externalities it happens when the perverse incentives economics of the bottom line of running a business.
[1:28:38] Online with what's good for all of humanity for Global health.
[1:28:42] And when were talking about the cost of drugs I mean remember those carbapenem drugs and prolastin these drugs of Last Resort. Well once you move from the first line of defense and you have to start using the second and third and then your last resort drugs will those cost go up exponentially from the second line of drugs being three times more expensive than the first option.
[1:29:04] And then those last-resort drugs can be 18 times or more expensive than those first line of drugs.
[1:29:09] And frankly just something that we cannot afford both in terms of lives and in terms of dollars.
[1:29:15] So David you usually ask me this question but I'm going to change things up and ask you what can we do. What Can We Do?
[1:29:22] I'm glad you asked Daniel because I've been itching to tell everybody this whole show and of course the first thing is invented magical drug that cures all this. That would be good to Nanobots that fly through a blood stream shooting at the enemy bacteria and viruses that B that would fix this problem.
[1:29:40] But also the integration of humans with uploading a.
[1:29:43] Uploading a brain to the singularity yet that's good then we don't have to worry about this.
[1:29:45] Upload our brains yes also if we can somehow get ourselves to conform to blockchain technology so that the bacteria can't track which cells to attack.
[1:29:56] Well if we had blockchain cells we could just jump back to where was in a previous date and would be fine.
[1:30:02] I think investing a lot of money into expedition to discover the Fountain of Youth and or the Holy Grail both of those would be very big for for medical science.
[1:30:12] Also we find that politically that's a huge waste of resources, when we're sending the Magic School Bus to do basically what is what what I consider to be Museum trips in children, for the purpose of Education look that's all great but we have a resource here at the Magic School Bus which could be look we need to use this. For treating disease.
[1:30:35] Controversial take their butt.
[1:30:37] Call me crazy. What Can We Actually Do?
[1:30:38] In all seriousness there are number things that we can do to help with this and we are actively working on all these problems right now.
[1:30:45] To the veterinary feed directive that passed beginning of last year will that was very important and laying down regulations that'll help us control this antimicrobial resistance in livestock and eliminate some of those zoonotic antimicrobial resistant diseases. Spreading that kind of legislation around the world two countries that don't have any place like China like India well that'll be a huge factor in in helping with this.
[1:31:06] Stewardship by doctors making sure this is something that we mentioned with our guest. Making sure that they are being responsible in the way that they prescribe medicine prescribed antibiotics to patients making sure patients followed the whole pack of their prescription treatment plan so that we aren't. Stopping before the full treatment is completed possibly giving in the chance of this bacteria to develop that resistance and then lie dormant in the body are spread out into other systems. Looking away some from industrial agriculture things that we talked about with Chris still asunder when is episode in episode 16 but we reap vegetarianism is a possibility for getting away from large-scale animal agriculture.
[1:31:43] You know I think dr. love brought up a good point which is so much of the unsustainable practices going on in the industrial agriculture is. Being driven by our need to grow our population and if we are going to rely on this indefinite growth. And we Face a world of 10 billion people that we now have two fees and we have these unsustainable dietary lifestyles, High meat consumption maybe in the face of global top soil being completely depleted in perhaps 60 years. Again maybe we should question that growth and instead of trying to fit our industrial agricultural practices to the model of indefinite growth we need to start questioning the sanity of that growth in the first place.
[1:32:28] These are all really excellent points and overpopulation what is sustainable what are carrying capacities are really tricky. Topics that a lot of people get defensive and contentious about and something that we will discuss. And varied great that's in the future there's a lot to unpack there but those are all good things to start thinking about now and again it and if you listen to have thoughts on the subject please feel free to reach out to us and we might indicate that with that show when we get started with it. And it's easy to fall into the Trap of discussing Health Solution to this problem because it's at first glance is a health problem but there also is an economic component to this. So we mentioned in our interview with researchers that may be part of the problem is that we don't have time. To take care of ourselves when we do get sick and that pressure is US pressure is Mother's pressure is father's precious individuals to try and jump on antibiotics to quickly get over disease because they don't have time to get off work. You don't have time to stay home with a sick child and so you need them. Healthy or at least appearing healthy as quickly as possible so you can get back to being economically productive Society one that respects the health of its individuals. Really the health of the entire Society making sure everyone collectively is happy healthy and ultimately maybe and I hate using this word but it's true productive is one that also pays attention to the health needs of individual.
[1:33:44] Enough from the economic incentives from the perspective of companies sauces to use Etc and then it's a bit of a dangerous suggestion.
[1:33:54] Things we can do to maybe less than some of the regulatory restrictions on pharmaceutical companies to reduce the cost of producing a drug in to increase the. Speed at which new drugs can reach Market it's something about us we're going to have to take between what is healthy and in responsible. And also what we need as a society in terms of our help needs at this exact moment.
[1:34:16] Real quick although we try to hit Solutions at the end of each of these episodes really what we're here to do at ashes ashes is bring awareness to problems systemic issues so that. Awareness can fuel creativity. Addressed at finding Solutions and immobilizing people to execute solution so if there's something that we miss these shows in terms of the most viable solution. Don't rely on us as your source for the ultimate solutions to these issues we don't have all the answers and part of the reason why we bring it awareness to these issues it so that more people can be thinking about them and offering solution so. In addition to all these that you mention David also the listeners you are a solution.
[1:34:58] And as always that's a lot to think about what we hope it does get you thinking talking about this and sharing it with friends family neighbors and your community as a whole. If you want to learn more about any of this resources detail information or a full transcript of this episode you can find all that and much more on our website ashes ashes.
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[1:36:06] Next week we got a really great episode and one that's entirely devoted to talking about Solutions so if you're feeling a little bit depressed after this one be sure to tune in next week or excited but until then.
[1:36:18] This is ashes ashes.
[1:36:20] Bye.
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