Translator: Rhonda Jacobs Reviewer: Hélène Vernet
I want you to picture yourself as an ecosystem.
The trillions of microorganisms that live in you and on you
are as diverse and complex as any rain forest.
Like many ecosystems around the world,
there's a decent chance that yours has been, to some degree,
ravaged by civilization.
A lot of the work that I do involves
investigating damage that's been done to my patients' gut ecosystems
and trying to figure out how I can help.
I use interventions like nutrient therapies,
diet changes, pharmaceuticals and herbs
to do things like - extending my forest metaphor -
put out forest fires and feed the soil
and prune some things back and replant others.
But every week, I get multiple e-mails and phone calls to my office
asking if I can use a particular therapy for my patients and their ecosystems.
And in many cases, I have to say no.
Despite heartfelt pleading, heart-wrenching stories,
tears and sometimes bribe attempts, I have to say "No."
Even when I think that this therapy is likely to be beneficial,
even profoundly decrease people's suffering and be safe for them,
I have to say no.
This is the weirdest, grossest, most natural,
and perhaps the most powerful thing I do with my patients.
Most clinicians call it "Fecal Microbiota Transplantation" or FMT.
Most people just call it "fecal transplant."
It's the process of taking stool from a healthy screened donor,
mixing it with liquid,
filtering it to concentrate the bacterial portion,
and administering those bacteria to a sick person,
usually via a retention enema.
Feces is a stinky, messy,
magical mass of microbes.
(Laughter)
And we don't often think of it as medicine.
But in this case, it can be.
It's kind of like the dank soil of an old-growth forest,
teeming with life.
And fecal transplant can be like taking a truckload of soil
from an old-growth forest
and moving it to a burn site or a clear-cut to repopulate.
A lot of animals do some version of this, it's called "copraphagy,"
and some animals even need it to live.
The first human recorded use of this is from the 4th century,
a Chinese physician named Ge Hong wrote about this.
And in modern times, the first recorded usage
is from here in the United States, from 1958.
A group of physicians wrote about a series of patients
who were dying of an infectious colitis.
Their diarrhea was so bad they were on the brink of death.
Having exhausted all of their options, these doctors did something fearless.
They broke one of the deepest human taboos,
and they took human stool, blended it, and filtered it,
and gave it to their patients as an enema.
And, miraculously, their patients were saved from the brink of death.
In fact, within 48 hours, all of their symptoms had gone away.
The docs in 1958 were almost certainly battling an organism
called "Clostridium difficile" or C. diff.
It's difficult to grow out; it's difficult to battle.
It produces toxins that cause damage to people's colons
and can even lead to death.
In the United States today,
half a million people a year are infected with Clostridium difficile,
and of that group, a little over 5% die because of it,
a little over 26,000.
Just putting that in context,
about 13,000 people die of AIDS-related illnesses in the United States every year.
C. diff is characterized by frequent, profuse,
excessively foul-smelling yellowish diarrhea.
It most often strikes when people's healthy gut ecosystem
has already been disturbed by taking a course of antibiotics.
Traditional medical therapy is - you guessed it - more antibiotics.
But this actually works.
About 65% of the time,
people who've received a single course of antibiotics
get better from their C. diff, and they stay better.
But, of that group that relapses,
the odds are less good of them getting well and staying well with antibiotics.
And each time you relapse, your odds decrease.
Using fecal transplant,
in the best scientific literature and in my practice,
is able to cure these people over 90% of the time.
It's a lot of lives saved.
These are the people who call my office,
and I get to say, "Yes, I can use this therapy to treat you!
Thank you, FDA."
You see, the FDA has not approved fecal transplant for any indication.
And, two years ago, they defined "poop" as a drug
when it's used as a medical intervention.
But, the benefits are so stupendously clear
when used for C. diff colitis,
that they have given clinicians in the United States
permission to use it anyway.
Before the FDA defined poop as a drug,
I was using fecal transplant for people with a variety of indications -
autoimmune inflammatory bowel diseases,
like ulcerative colitis and Crohn's disease,
refractory, tough-to-treat irritable bowel syndrome,
multiple sclerosis and other things.
Because interestingly enough, what happens in the gut
can have profound impact on what happens in the brain
and on inflammatory and immune functions globally.
This is the group of people
that I have to tell no when they call my office at this time,
since the FDA's guidelines, two years ago.
So why has the FDA called poop a drug?
It's because it is so clear
that this therapy can prevent and treat disease,
that they say, "Well, if it can prevent and treat disease, it's a drug."
I'm a naturopathic doctor, or N.D., by training,
so for me, this is a stretch.
The entire foundation of my profession is that we can use things
that are not drugs to prevent and treat disease.
I can and do prescribe strong antibiotics
and powerful immune suppressants for my patients when they need them,
but I give probiotics with the antibiotics
to try to prevent C. diff and other bad outcomes.
I give DHEA when I prescribe Prednisone to try to prevent bone loss,
depression and insomnia and other things.
I use saffron and St. John's wort for my patients with depression,
and I use wormwood and vitamin E
for my patients with inflammatory bowel disease,
and the list goes on:
all things that are not drugs to prevent and treat disease.
Despite the fact that I am a person who takes poop,
centrifuges it to remove the 90% that is not bacteria,
and then triple encapsulates the bacterial portion
and gives it to my patients to take orally,
when the FDA tells me that poop is a drug, I have a hard time swallowing that crap.
(Laughter)
I want to tell you the story of my youngest FMT patient.
Landon's mom called me from a hospital in Kansas
because Landon, at less than two years old,
had been diagnosed with an autoimmune condition called "ulcerative colitis."
His immune system was causing so much inflammation in his gut
that it was eating holes, or ulcers into it,
and he was bleeding from those ulcers so much,
he'd required three blood transfusions in the previous couple of months.
She wanted to know if FMT could help.
At that time, there were no reports
of using FMT for children in the literature - zero, not one -
and I hadn't used FMT for children in my own practice either.
So I had to tell her, "I don't know. We don't have data.
I don't have experience about 'Could this be beneficial for Landon?'"
But, based on my experience with adults with ulcerative colitis,
if this were my child, I would absolutely try it,
as soon as he was medically stable.
So shortly after he was discharged,
Leslie and Landon flew to Portland to my office.
And I remember that office visit.
Landon was a bright, fun, sparkly toddler.
He needed three diaper changes during that first visit,
and there was as much blood as stool in all of them.
This was a sick kid, having ten or more diapers like this a day, every day.
His mom and I figured out how to do pediatric fecal transplant,
and we watched over the course of a week and a half,
as his stool frequency decreased,
his stools became more formed, and we saw less and less blood,
until there were days when he was having
two or three formed, bloodless bowel movements per day.
Landon's story is complicated with ups and downs over the years,
but I'm happy to say that today, he's doing phenomenally.
I talked to his mom just a couple of days ago,
and it's been over a year since he's had any symptoms
or used any drugs to affect ulcerative colitis.
It's as good an outcome as we could have hoped for.
Indeed, when I look at the medical literature for safety and efficacy data,
I'm astounded.
FMT appears to be as beneficial
for people with stubborn inflammatory bowel disease
as the newest, most expensive and modern IV immune-suppressant drugs
but without the increased risk of cancer
and other serious adverse events that we see with the drugs.
Now, the studies are smaller and they're early,
but so far, they look amazingly optimistic.
A colleague recently remarked to me that we used to live in a world
where exposure to feces made us sick, and antibiotics saved our lives.
Now, we live in a world where antibiotics are making us sick
and feces saves our life.
I no longer think of my patients as just themselves.
I think of them as a garden to be tended,
or sometimes, as an entire galaxy filled with trillions of lives.
I think of our decisions, as a society and as individuals
to give antibiotics to our cattle to fatten them up,
to use antimicrobial soaps and our diet changes
like the decisions of the gods of old,
whose decisions ripple out among trillions of lives across a galaxy.
If there's a take-home message here,
it's to tend your own garden.
Eat diverse fiber foods at most meals.
Don't take antobiotics casually.
Let the dog lick the kid.
(Laugher)
I think that knowing our own internal garden,
knowing the flora and the fauna, the weather and the soil,
is knowing ourselves.
I think that knowing how to nourish that ecosystem,
and even how to completely reboot it when necessary,
may be the most high yield area of medicine today,
and I thought that that was an idea worth spreading.
(Applause) (Cheers)
Thank you.