36. Creatively Combating Antimicrobial Resistance

Contagious Conversations  /  Episode 36: Creatively Combating Antimicrobial Resistance





Dr. Judy Monroe: Hello, and welcome to Contagious Conversations. I'm Dr. Judy Monroe, President and CEO of the CDC Foundation and host of today's conversation. Every episode, we hear from inspiring leaders and innovators who make the world healthier and safer for all of us. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit, that builds partnerships to help the Centers for Disease Control and Prevention save and improve more lives.

Joining me today are Dr. Meghan Perry, and Ella Balasa. Dr. Perry is an infectious disease physician in the Scottish National Health Service and a senior clinical lecturer at the University of Edinburgh in Scotland, whose experience with infectious diseases and antimicrobial resistance sparked the idea for a musical titled The Mold That Changed the World, which details the life of Dr. Alexander Fleming, the discoverer of penicillin. Ella has endured a lifelong battle with cystic fibrosis and has experienced lung infections by bacteria that are antibiotic resistant. Her journey led her to become a patient advocate for cystic fibrosis.

In this episode, we explore the power of the arts to promote key public health messages and health protection behaviors and the power of patient advocacy in raising awareness about public health issues, like chronic diseases and antimicrobial resistance.

So welcome, Dr. Perry and Ella.

Meghan Perry: Thank you.

Ella Balasa: Thanks for having me.

Judy Monroe: So Dr. Perry, I'll start with you. You're an infectious disease doctor who came up with this idea for a musical, called The Mold that Changed the World, which details Dr. Alexander Fleming's discovery of penicillin. Can you tell us about your background and how you became involved in this production?

Meghan Perry: Well, first of all, thank you so much for having me on this podcast. I'm honored to be part of it. A little bit about my background, well, I'm a specialist in infectious diseases, and I wrote my PhD on resistance in a parasite called Leishmania. And I was out in India doing that. And I came back and I was like, ‘I want to focus on resistance that I see every day in Scotland.’ And through doing that, I realized that, potentially, the public and my colleagues, some of my colleagues, who were not focused on infectious diseases, were taking antibiotics for granted. And they are so very precious. And that is my mantra, and that has pushed me through this whole project.

As well as being a doctor, I'm also a musician, and I live in a world outside the hospital with lots of amazing creative people. And through that, I met a very talented composer and playwright called Robin Hiley. And he was telling me about the fact that he wrote musicals for children with a historical perspective. And through that, I had this idea that actually, perhaps, if we were able to write a musical about antibiotics, we could catch children at a really early age and influence their health beliefs about how important antibiotics are and then change their health seeking behavior for the rest of their lives. This was also partly inspired by how active children have been in the fight against climate change as well. So I put this idea to Robin, bless him, at a dinner party. And so, he got a bit of a shock, but he was into it.

And we were very lucky to get funding from the British Society of Antimicrobial Chemotherapy, who supported this very left field idea of developing a musical, of writing songs where you are trying to rhyme flucloxacillin with resistance and talking about all sorts of diseases. The project has grown from just focusing on children performing to now a professional production, where we have professional actors performing alongside professional antimicrobial pharmacists, public health physicians, public health workers. As we know, we've performed it at the Edinburgh Fringe, and also, now the musical has come on tour to Atlanta and Washington, DC and had a very successful time there.

Judy Monroe: Yes, it was very successful here in the United States, and I love how you brought in the children. I love that starting point with the youth, but obviously, the adults as well. It's such an important story to tell. I can only imagine that Robin Hiley might have had some eyerolling when you ask him to write a musical about antibiotics.

Meghan Perry: I think there's a story in any public health crisis. The public health crisis has come as a result of human behavior. And human behavior comes with a story, and this story that we're telling, through The Mold That Changed the World, it's sort of almost in three parts. Because we detail in the musical, without giving away too much, but we detail in the musical what life was like without antibiotics, and then, this tremendous and exciting, miraculous discovery and how everybody, the soldiers in World War II, were able to survive in the second part. And then, in that final part, we see the human's abuse of antibiotics and the fact that we're starting to lose their power and how urgent and very concerning that is for everyone.

Judy Monroe: Well, thank you for that. And as you said, they are very precious. Antibiotics are very precious. So Ella, you were diagnosed with cystic fibrosis when you were just an infant. Tell us about your journey with the disease.

Ella Balasa: Yes. Well, again, I want to reiterate thank you for inviting me onto this podcast. It really is an honor. So cystic fibrosis has affected me since I was an infant, very young child, where I was diagnosed at 18 months. So prior to that, my mother said that I was experiencing a lot of respiratory infections, upper and lower respiratory, a lot of ear infections, very underweight, due to cystic fibrosis. And so, finally, when I was diagnosed, it all kind of fit together, and I was then started on antibiotic treatments to reduce the infection in the lungs. For those that are unaware, who are our listeners, cystic fibrosis is a genetic lung disease primarily, and it affects the lungs, where mucus builds up in the lungs and then traps bacteria. And this leads to lifelong infections and this cycle of infection and inflammation. The body then leads to lung function deterioration, and then, eventually, a shortened life expectancy.

So over the course of my life, I've had many, many hospitalizations, ever since that first one when I was 18 months old, to treat these persistent lung infections with intravenous antibiotics. So antibiotics are the primary and really the only effective treatment for these lung infections with cystic fibrosis. And over time, the more frequent use of these antibiotics has led to antibiotic resistance, where these bacteria, that are colonized in my lungs, are no longer susceptible to or affected by the antibiotics that I'm being treated with and that I'm dosing into my body. And so, in 2019, I got very, very ill with one of these lung infections, with a bacteria called pseudomonas aeruginosa. And this is the bacteria that I have grown in my lungs for many, many years, and my body wasn't responding to any of the three IV intravenous antibiotics that I was taking, including colistin, which we know is one of the strongest that we have available to us today.

And I was really on the brink of death, I would say. I had about 18% lung function. So I was on supplemental oxygen for 24/7, really could barely breathe to perform any sort of daily functional activities in my life. And it was at that time that I then resorted to using an experimental treatment, called phage therapy. And we don't need to dive into that right now, but if our viewers want to do their own research on it, this was something that became available to me through expanded access. So through a single just one use case for me. And it did help to treat my infection at the time. But really, since then is when I, and we can talk about this too later, but I really saw the value that I had in being an advocate for my own care and in getting this treatment and really the need for spreading awareness about antimicrobial resistance for populations that use antibiotics chronically, like the cystic fibrosis population, and how it's just a growing problem globally.

Judy Monroe: So as you've just described, antibiotics clearly are lifesaving with cystic fibrosis. They're essential. And we have growing antimicrobial resistance worldwide, which is a major problem. And as you've described, the new therapies. So we need innovation on multiple fronts with this problem. So Dr. Perry, I don't know if you want to speak to some of the innovation therapies that Ella just spoke about.

Meghan Perry: I think that antimicrobial resistance, as an issue, needs to be approached from multiple different angles. There's no one way that we are going to solve this. Using things like the musical try and decrease unnecessary antimicrobial usage, but that isn't the case with Ella. Ellen needs to take multiple antibiotics to try and clear the infections from her lungs, and those bacteria are going to learn to resist. So we need innovation for Ella, and that innovation can be in the drug space and new antimicrobials with new mechanisms of action. We know that that's been a very slow process, due to the economics of drug development, which is very challenging, but also, innovation in other ways of treating infection that aren't using antibiotics. So, using the phage therapy, and we know there's a lot of research going on in the world of antimicrobial peptides, so how bacteria can produce other kinds of molecules, which can have bactericidal or bacteria static activity.

And then, incredibly important is making sure that the source of the infection is well controlled. So a major part of Ella's care will have been physiotherapy. And without the physiotherapy to clear the secretions and everything that's coming from her lungs, then it would be even more difficult for her to clear an infection. And just making sure that we're getting really good diagnostics and really good early source control. So we are never giving antibiotics when we don't need them. A simple example of that, I run a recurrent urine tract infection clinic in my day-to-day job with a consultant urologists. And we find, quite often, that we'll have patients that just aren't managing to empty their bladder properly, and they've had multiple courses of antibiotics.

But of course, they're not going to get better, because the bladder's full and it's not emptying properly. And so, if we can get in earlier there, with that kind of diagnostic, then, again, that's another kind of antimicrobial stewardship to stop that resistance developing and stop the antimicrobial usage. There's that wonderful paper also from Ramanan Lakshminarayan, who is a hero of mine, about looking at social determinants of antimicrobial resistance and the importance of, for example, our waste infrastructure within countries. And so, that kind of political aspect of saying, ‘This is so important, because this spreads antimicrobial resistance as well. And we need to combat that, so that we can save money in the future and save lives.’ So it's not just in the medical field. It's so broad ranging.

Judy Monroe: We’ll be right back with Dr. Megan Perry and Ella Balasa.

The power of the arts helps promote understanding of key public health issues and health protection behaviors, while fostering partnerships and creative health messages through innovation. The COVID-19 pandemic reminded the world of the threats posed by infectious disease and the value of medicine as a life-saving resource. Despite tremendous advances in the development of antibiotics in the 20th century, germs like bacteria and fungi continue to develop the ability to defeat these medicines, leaving us vulnerable to deadly disease. Through a play called The Mold That Changed the World, that story is being told in a uniquely creative way. The CDC Foundation is proud to provide support with other partners to bring this play to audiences in the United States. Learn more at mouldthatchangedtheworld.com.

Now, back to our conversation with Dr. Perry and Ella.

Well, and that brings us back to The Mold That Changed the World, because as we have just seen and heard from Ella, the importance, she must have antibiotics. But then, there's this overuse or misuse of antibiotics that the general public needs more awareness about as well. And so, The Mold That Changed the World is such a powerful way to tell the story of the discovery of penicillin. As we've said before, it's had great reviews. And understandably, I think, people don't often see an immediate connection between art and medicine. You're a musician as well as an infectious disease physician. So what unique opportunities do the arts present for public health messaging?

Meghan Perry: Well, I was very lucky. When I was a medical student, I did my elective out in Tanzania, and I actually saw firsthand the uniqueness of drama in conveying public health messaging. And on two fronts, just in three months out there, and one was a traveling play about the transmission of HIV and how that worked. And the other was to do with female genital mutilation and the deleterious other health effects that could have. And it was teaching tribes, Maasai tribes, about the dangers. And both of those were so powerful within the communities that I was working on for my elective. And I think I took that message home, and then, it came back out when I was given this opportunity to meet Robin and then develop The Mold That Changed the World. Musicals, obviously, I'm biased from that perspective, but this plays, drama, art, we saw some beautiful art in Atlanta, that was being exhibited at the same time as The Mold That Changed the World.

Anything that … the arts have got the ability to look at things from a new perspective, to evoke emotion, to tell a story in a way that isn’t statistic, that says our E. coli is 75% more resistant than it was five years ago. That doesn't mean anything to anybody. We had a lovely situation after a kid that watched The Mold That Changed the World, when we first developed it, and he had some impetigo. And he went to the GP, and the GP said, ‘Well, we could give you a cream or we could give you an antibiotic to get on top of it, just in case.’

And the boy said, ‘Well, I've just watched a play that says that I should not take an oral antibiotic. I'd just like the cream. Thank you very much.’ And we were really delighted by that. But I think this kind of just in case use of antibiotics has just got to stop as much as possible, because that kind of just in case might mean that it's not necessary. And we want to be prescribing antibiotics with diagnostics, to people like Ella, who really need them.

Judy Monroe: So Ella, talk to us about your becoming a patient advocate as well. Maybe how the arts might even be used in your advocacy.

Ella Balasa: Certainly. Yeah. So actually, to add to that Meghan's point, I think visuals and movies and video representations are very eye-catching. And that's what people, I think, remember, even when it comes to social media. That's why all these platforms that host short video clips are so engaging. And so, that's a means by which I've been involved in spreading awareness of antimicrobial resistance. I was recently part of a documentary, called The Silent Pandemic, and it was discussing the global problem of AMR and taking a really holistic perspective on it and incorporating even how antibiotics are used in agriculture and in farming and the problem with that and how resistance is spread that way. And that adds to one of Meghan's points previously. And so, to backtrack a bit, after I received that treatment, that I was detailing earlier, in 2019 and how it helped my infection, and from there, I really wanted to spread awareness about this, about AMR, and the problem of these infections.

And so, I started sharing about that experience publicly, and I wrote some articles about it and had that published. And then, I was invited to speak at a number of conferences and panels and even joining a couple of advocacy organizations that are working towards policy changes and bringing and also, fueling innovation and investment into the antibiotic space. So I attended, like I said, a number of congressional meetings as well. Then also have been a part of a couple of these documentaries, some that were sponsored by pharmaceutical companies, that were developing antibiotics, and then some that are more just bringing public awareness through national television and things in the news stations as well. And most recently, I have been on a couple of radio stations, talking about my condition and the need for investment into new therapeutics and novel mechanisms of treating antibiotic resistant infections.

Really, the last three years have been spent working as a patient advocate in this space and doing my part in bringing awareness to it and how, I think, it all really begins from awareness and having the public understand why it's a problem, why we do need stewardship, and why we shouldn't be overusing antibiotics and the problems that exist globally, worldwide, in other countries as well, with problems with sanitation and all that and farming. And so, I think, when we are able to bring a greater understanding and awareness, that's when changes can occur. That's when there can be policy implementations. That's when more the public can be say, ‘Hey, we need new antibiotics developed,’ and spur that action from industry as well. So, it is really a mutual effort, very much a multi-stakeholder effort. And I think, as a patient, having that lived experience, I can really, I think, back to sort of the arts and the storytelling, I think that that is such an important component of touching people and really affecting and having a story that then affects change.

Judy Monroe: Along with that, do you think medical professionals can better communicate, both to their patients and to the public, the threats posed by AMR and steps that maybe they can take to avoid contributing to the drug resistance? I will tell you, I know a lot of physicians feel under pressure when patients are demanding antibiotics or some may be a little too quick to prescribe the antibiotics. So thoughts on that?

Ella Balasa: I think, in the United States, there is just a culture or, I guess, a practice of just having a quick fix for any ailments, and prescribing antibiotics is part of that. And this comes back to educating the public. People need to be aware that you don't need antibiotics for a viral infection. Let your body fight off with its immune system itself. And so, I think, creating awareness in that regard would then put less pressure. The patients would be putting less pressure on their physicians for ‘I'm coming to you as a doctor, I need something to solve my problem and my condition.’ And so, I think that that would alleviate a little bit of pressure on doctors for prescribing and getting these antibiotic treatments.

Meghan Perry: Yes, certainly, I've been trying to push the antimicrobial stewardship agenda in different training specialties, not just within infectious diseases. Everybody needs to spend a lot of time thinking about antibiotics. I think another aspect, with the family physician interface, which is particularly challenging for the US, is that it's a consumer system. And Ramanan Lakshminarayan talks about this as well, this kind of issue that, if people want antibiotics and they go to a family physician doctor who doesn't prescribe them, then they'll go ahead and find someone else. And so, there's an kind of economic drive almost for the physicians to be prescribing, which must be incredibly challenging for them. And unless, as you say, we can actually get through to the community, that antibiotics are not always required then and we're going to get caught in this loop for forever after.

Judy Monroe: Exactly why I think The Mold That Changed the World is so brilliant. What a wonderful approach. And obviously, through other arts as well. So as The Mold That Changed the World cautions audiences about the threats of antimicrobial resistance, Meghan, do you have thoughts about other emerging public health issues that you think might be ripe for such unique messaging into the future?

Meghan Perry: Do you know, Robin and I have talked about this before, and I think quite soon after the first performance, a friend, who was a bariatric surgeon, says, ‘Robin, please, will you write a musical all about obesity?’ And that's fascinating. There'll be a story in there, a personal story, a historical story, a social story, that could all be interwoven. And homelessness, climate change and health. There's so many different aspects where the arts can tell a story and tell a powerful and evocative story that could change people's perception. I love the fact that, not only are we trying to encourage and inspire the children, but we are giving the adults a voice as well to get out there. And I hope that maybe this model could be used in the future again for other important public health crises.

Judy Monroe: I love that. I love that. Any last words of wisdom to our audience that you'd like to give before we wrap up?

Meghan Perry: I think I'll just go back to what I said at the beginning, that I just want everyone to know how precious antibiotics are and to just always take care of them and only take them when you absolutely need them.

Ella Balasa: Yeah, I would echo that as well. And also, encourage people or listeners to spread the word. If they're listening to this and they're new to understanding how antibiotics work and why we do need to conserve them or have stewardship and gaining more understanding and awareness, spread that within your communities and make other people aware of the problem of antimicrobial resistance. I think that that's the way that we're going to begin this shift of changing and innovation and, hopefully, saving and improving people's lives.

Judy Monroe: Well, Ella and Meghan, thank you so much for joining us on Contagious Conversations. Your personal stories, as a physician and as a patient, really made for a powerful discussion. And it was just great to speak to both of you. Thank you for all that both of you are doing, and thanks for joining us again.

Meghan Perry: Thank you for having me.

Ella Balasa: Thank you.

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