24. The Power of Poop

Since the beginning of civilization, we’ve thought that human waste was worthless and dangerous. What if we were wrong?

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:01Stephen J. Dubner?

  Freakonomics Radio is sponsored by PNC Bank. Boring, great word, bad rep. Yet, time and time again, here at Freakonomics, we find that when something culture-changing happens, boring things like calculations and careful planning are usually behind it. Which begs the question, why not apply it to other aspects of life, like banking, for example? Well, PNC Bank did, since its inception, proving time and again that the best banking strategy isn't the exciting type, but the steady, reliable, definitely-not-yolo type. PNC Bank: brilliantly boring since 1865. Brilliantly boring since 1865 is a registered mark of the PNC Financial Services Group, Inc. PNC Bank, National Association, Member FDIC.

• 0:48Stephen J. Dubner?

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• 1:20Stephen J. Dubner?

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• 1:53Stephen J. Dubner?

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• 2:32Stephen J. Dubner?

  About 20 years ago, William Costopoulos had his wisdom teeth taken out. It didn't go so well.

• 2:39Speaker 01

  I had a laryngeal spasm on the operating table and when I came to, I was shattered. They thought I had a stroke. You know, I was dribbling, my eye was funny, I couldn't see properly. I looked like I had lost oxygen.

• 2:56Stephen J. Dubner?

  Costopoulos hadn't had a stroke. It turned out that he was showing some early symptoms of multiple sclerosis.

• 3:02Speaker 01

  This persisted for about three and a half, four years after that. You know, pain, optic neuritis, they gave me, they'd done CAT scans, they'd done all sorts of things. And then one particular doctor decided to get an MRI done. And the MRI after the optic neuritis, the optic nerve was playing up, you know, it was going all cloudy and I couldn't see properly out of my left eye. A particular doctor asked me to get an MRI scan and the MRI scan came back with a whole lot of other issues, with me having MS and lesions and the whole shebang. If you saw me then, you'd say, "This guy, you can forget this guy. He's going nowhere."

• 3:47Stephen J. Dubner?

  No one is a good candidate for MS, but Costopoulos was an especially outgoing and outdoorsy guy, the kind of Australian that Americans like to put in beer commercials. For Costopoulos, the prospect of gradually losing more and more control of his body was devastating. And then, a fateful trip to the hair salon.

• 4:09Speaker 01

  I came to know Dr. Brody through my wife, who, she used to cut his hair because she had him to salon in Five Dock. And that's how I got to know Dr. Brody.

• 4:22Stephen J. Dubner?

  And why did you go to Dr. Brody for treatment?

• 4:25Speaker 01

  Because he was very, very concerned about my health. He saw, he's known me for years through my life, and when he saw me get ill, he was very, very shattered and very concerned.

• 4:38Stephen J. Dubner?

  Dr. Thomas Barodi is a gastroenterologist in Sydney. Now, if you're like me, you immediately think, what's a gastroenterologist who treats ulcers and diarrhea have to do with MS? But Barodi isn't your typical gastroenterologist. He is, to put it mildly, a bit of a medical maverick. The treatment he tried on William Costopoulos was something that most of us, something that even most doctors would find unusual and perhaps unsettling. But then, it apparently worked.

• 5:10Speaker 01

  It didn't, it wasn't an overnight occurrence where, you know, I got better like within 15 seconds. But all I know now is, I'm 47 years old, I ride a custom chopper, I travel the world, I have a great time, and I'm not in the bloody wheelchair, right? That's all I know.

• 5:31Stephen J. Dubner?

  So what happened? What does a gastroenterologist in Sydney know about treating MS? Here's a hint. It has something to do with the trillions of microorganisms that live inside your gut. It has to do with, there's really no easy way to say this, it has to do with poop.

• 6:05Speaker 02

  From WNYC and American Public Media, this is Freakonomics Radio. Today, the power of poop. Here's your host, Stephen Dubner.

• 6:21Stephen J. Dubner?

  The history of medicine is a strange one. It's filled with missteps and misdeeds and seemingly obvious solutions that took too long to discover. Take hand washing. It wasn't until the middle of the 19th century that doctors realized it was a good idea to disinfect their hands between handling a corpse and delivering a baby. Dr. Thomas Barodi is trying to rewrite his own corner of medical history. He's a member of a small but growing band of doctors who are pushing the frontiers of medicine in a decidedly strange direction.

• 6:56Speaker 03

  Fecal matter, I was brought up to believe was waste, but we've now learned that it's the largest organ of the body. It contains about nine times more living bacteria, bacterial cells, than the body contains human cells. So, in a manner of speaking, we are 10% human, 90% poo.

• 7:14Stephen J. Dubner?

  The importance lies in the bacteria. We know bacteria can do wonderful things, like help us digest food, and terrible things, like cause infection. Thanks to advances in DNA technology, medical researchers are getting better at figuring out which bacteria do what, and when, and why. This is leading to a new understanding of disease. The idea is that many ailments, from constipation to MS to obesity, may be caused by missing or damaged intestinal bacteria. So, what if you could take healthy bacteria from one person and put them inside a person

• 7:59Stephen J. Dubner?

  who's ill? That's what Barodi did for William Costopoulos's MS. He performed a fecal transplant.

• 8:09Speaker 03

  Now, when the stool is infected with a bug, when we change the flora by implanting another person's stool, that other person may contain bacteria which manufacture antibiotics. And this is the key. Bacteria make molecules that kill other bacteria. In fact, most antibiotics come from bacteria, such as vancomycin, for example. And you will remember fungi produced penicillin. So it now physiologically makes good sense that when you implant flora from a healthy person into a person who's got infected flora, that infected flora may be cured by that single implantation.

• 8:45Stephen J. Dubner?

  That's right. The doctor takes some fecal material from a healthy person, a fecal donor, and transplants it into the patient. And just like that, the good bacteria have a chance to flourish where the bad bacteria once ruled. Barodi has been performing fecal transplants for more than 20 years. He began by treating diarrhea and constipation.

• 9:07Speaker 03

  In fact, my mother was the first patient ever, and she was cured. And it's interesting because my father was a donor, and he has passed away, but his poo lives on, in a manner of speaking.

• 9:20Stephen J. Dubner?

  Other researchers are holding their noses and diving in as well. In 2003, a team of researchers in Germany found a possible connection between the intestinal tract and the path that Parkinson's disease takes as it attacks the nervous system. Barodi himself has treated a few Parkinson's patients by focusing on fecal bacteria, successfully, he claims. And he's currently setting up a medical trial to prove that he's right. It should be said that Barodi's work is not greeted with universal enthusiasm by his fellow physicians, which, in the scope of medical history, is pretty typical. Barodi points to the case of Barry Marshall, a fellow Australian gastroenterologist. Marshall became convinced

• 10:05Stephen J. Dubner?

  that peptic ulcers were caused not by stress or spicy food or stomach acid, as most people believed, but by a bacterium called Helicobacter pylori.

• 10:16Stephen J. Dubner?

  His theory was roundly dismissed. And so Marshall swallowed some Helicobacter pylori and proved his theory correct. Then he made himself well again with antibiotics. Years later, he won a Nobel Prize.

• 10:34Speaker 03

  Well, the feedback is very much like Barry Marshall's. I was initially ostracized. There was a program on our ABC radio where a professor of medicine named me as being a charlatan for doing fecal transplants, and he had no idea of the science behind it, very much like those people who initially criticized Barry Marshall. And initially Louis Pasteur was also criticized like this, and so was Edward Jenner with immunization for smallpox. So I don't expect anything different. But even now, I have my colleagues would, you know, avoid talking about this or meeting me at conferences. Although this is changing.

• 11:16Speaker 03

  I've just had an invitation to speak at an international conference about fecal transplantation dash the state of the art. So I think we might be turning a new leaf, and I think we should with Poo especially.

• 11:32Stephen J. Dubner?

  One thing that might help Barodi turn a new leaf is a catchy name. I tried to help him come up with something, but he was way ahead of me. So can't you call it flora therapy? That just sounds like some rose petals being sprinkled about.

• 11:46Speaker 03

  I mean, one patient came back six weeks after, and she, with a straight face, not understanding what she was saying, said, "Doctor, when I had my transpusion." So, you know, we could use all terminology.

• 11:57Stephen J. Dubner?

  There you go. A transpusion.

• 12:05Stephen J. Dubner?

  Coming up, the transpusion takes root in America, too.

• 12:30Stephen J. Dubner?

  Freakonomics Radio, sponsored by Granola. You know that moment when a meeting ends and someone says, let's circle back on this next week, and everyone nods, but no one writes it down? Then next week rolls around and it's radio silence? That's why Granola exists. Granola is an AI-powered notepad built for the way real people actually meet. You take rough notes like you normally would, and in the background, Granola securely transcribes the meeting. Then it turns everything into clean, structured, actually useful notes when the meeting ends. And the best part? Granola works through your device's audio, which means it integrates seamlessly into the video conferencing tools you already use. No setup, no awkward bots. It's just your normal meeting with superpowers. If meetings are eating up your day, Granola is a no-brainer. You can try it totally free.

• 13:14Stephen J. Dubner?

  Just head to granola.ai/freakonomics. That's granola.ai/freakonomics to get your time back. Try it for free at granola.ai/freakonomics. Freakonomics Radio is sponsored by Southern New Hampshire University. The best investments are the ones you make in yourself, and no one knows that better than Southern New Hampshire University. With more than 200 online degree programs, no set class times, and low online tuition, Southern New Hampshire University is built to fit your life today and set you up for success tomorrow. Education is an investment. Why not make it a smart one?

• 13:55Stephen J. Dubner?

  Apply for free at SNHU.edu/freakonomics. Freakonomics Radio is sponsored by PNC Bank. Boring. Great word, bad rep. Yet, time and time again, here at Freakonomics, we find that when something culture-changing happens, boring things like calculations and careful planning are usually behind it. Which begs the question, why not apply it to other aspects of life? Like banking, for example? Well, PNC Bank did since its inception, proving time and again that the best banking strategy isn't the exciting type, but the steady, reliable, definitely not YOLO type. PNC Bank: brilliantly boring since 1865.

• 14:39Stephen J. Dubner?

  Brilliantly boring since 1865 is a registered mark of the PNC Financial Services Group, Inc. PNC Bank, National Association, Member FDIC.

• 14:54Speaker 02

  From American Public Media and WNYC, this is Freakonomics Radio. Here's your host, Stephen Dubner.

• 15:08Stephen J. Dubner?

  American researchers are looking into the medical value of poop as well. At the University of Minnesota, Alex Koritz is combining his background in immunology and gastroenterology to explore just how useful fecal flora might be. His latest research looks at a possible connection between fecal flora and obesity, and he plans to run a trial in which obese people get a transpusion from healthy, trim people. Most people, when they think of human waste, they just think, you know, ew. What do you think of when you think of human waste?

• 15:47Speaker 04

  Well, part of me has not overcome that feeling. I think it's universal. It's evolutionarily put in there. We're supposed to avoid the stuff. But I also realize that what it represents is shedding of our microbial organ. So I also think about all the functions that that entity has. And it's essentially like elephant in the room for a gastroenterologist. We talk about all the other parts of the digestive tract, but we're so ignorant about

• 16:27Speaker 04

  this component that most gastroenterologists and other scientists know very little about it. And so our level of knowledge hardly exceeds that of a fifth grader, who just says exactly as he said, ew.

• 16:43Stephen J. Dubner?

  Now, I notice you keep calling it it. What do you actually call it when it's not it? What's your word for it?

• 16:51Speaker 04

  I think of it as a microbial organ. So it's just like an organ anywhere else in your body.

• 16:58Stephen J. Dubner?

  But we're talking about poop.

• 17:00Speaker 04

  We're talking about poop, yes. Well, poop is just, is what we see. It's a little more complex than that inside, but we can, we can detect or measure most of the constituents of this microbial organ in poop. And it's easy to get, that's what we study.

• 17:22Stephen J. Dubner?

  Now, talk to me, let's, let's jump forward a little bit and talk to me about the current state of fecal transplantation. What is it? How does it work? What does it achieve?

• 17:35Speaker 04

  Well, fecal transplantation actually is not something completely novel. And in the 50s, a, a, a serious complication was already described. This was called pseudomembranous colitis. People would develop diarrhea and sometimes they would get really, really sick. This would be so-called fulminant colitis. They'd become septic and the mortality of that was something like 75%. So in the 50s, people decided, well, we're probably messing up bacteria inside and what will happen if we just infuse them back?

• 18:18Speaker 04

  We'll take some fecal material from a normal, healthy donor and homogenize it with saline and infuse it in as an enema. And in fact, they've described these miraculous cures of people who were destined to die, given how sick they were. It was discovered in the 70s that this pseudomembranous colitis is caused by a particular infection, infection called Clostridium difficile.

• 18:50Speaker 04

  This pathogen has been getting smarter and smarter with time and has reached truly epidemic proportions. We treat the infection with other antibiotics. Usually we're successful, but obviously we fail a lot of the time. And so this procedure, which sounds pretty desperate, has had a resurgence. So what we did was try to measure composition of the different microbes before the procedure, look at the composition of the donor, and then see whether, in fact, we've engrafted

• 19:33Speaker 04

  the donor material into the recipient. Essentially, is this an organ transplant or not? And the result was quite remarkable. We were able to engraft the donor microbial communities to the extent that it was essentially indistinguishable from that of the donor. We, in fact, have done a true transplant.

• 19:56Stephen J. Dubner?

  What makes the gut so hard to study? Or what makes it so hard to study the microbial environment of the gut?

• 20:03Speaker 04

  So the microbial world, particularly inside the colon, is extremely complex. It contains, each one of us contains hundreds of different species of bacteria and other domains of life. And most of those critters, if you like, are impossible to culture in a laboratory by themselves. So it's a very complex world. And until the development of latest DNA technologies and computational techniques...

• 20:42Speaker 04

  It was inaccessible to study.

• 20:44Stephen J. Dubner?

  Like Barodi, Koritz performs fecal transplants himself, and he sees them as a potentially powerful answer to a host of important medical questions. But he's careful to say that these are early days.

• 20:58Speaker 04

  Well, we're yet to see whether it's going to be the solution to a lot of illness. It's too early. But when I got into the field, I was fully cognizant of all the potential ramifications and potentials. I mean, being a researcher, I was aware of this work being going on. I was aware that an entire new science was being born. And actually, I was almost salivating with envy. Oh, boy, I wish I was in that field. And it just so happened, as a gastroenterologist, I'm in the middle of that field. So I couldn't resist entering it. We're at the beginning of this new science. This is a wide-open new frontier.

• 21:45Stephen J. Dubner?

  Yeah, I know what you're thinking. You shouldn't salivate with envy when you're talking about fecal transplants. Let's face it. The whole thing is, on its surface, disgusting. But if we've been collectively wrong about poop, it would hardly be the first time we've been collectively wrong. Throughout civilization, problems thought to be unsolvable got solved. We humans innovate. We come up with cheaper, simpler, better solutions. Solutions that often turn conventional wisdom on its ear. All it takes is a couple of gutsy investigators willing to go to a dark place.

• 22:29Stephen J. Dubner?

  For millennia, human waste has been a frightful byproduct of our existence, a source of shame and disease. Wouldn't it be amazing if poop, as explored by doctors like Alex Koritz and Thomas Barodi, turns out to be a health breakthrough rather than a health hazard?

• 22:51Stephen J. Dubner?

  Brody can't say with 100% certainty that poop is why his MS patient William Costopoulos got his life back, but, well, he did get his life back. Did you ever give Dr. Brody a gift of any sort to thank him?

• 23:06Speaker 01

  No, actually, I've never done that. I've got to, I've got to give him something. I've never done that.

• 23:11Stephen J. Dubner?

  I'm not saying you have to. I was just asking the question.

• 23:13Speaker 01

  Yeah, no, actually, I've never given him anything. To be honest with you, he's always giving.

• 23:19Stephen J. Dubner?

  Maybe, you know, it might be nice, maybe you could install some new toilet paper rolls in his house. Some gold-plated toilet paper dispensers.

• 23:26Speaker 01

  Hey, I might go get some toilet paper printed.

• 23:29Stephen J. Dubner?

  Oh, there you go.

• 23:30Speaker 01

  Just especially for him.

• 23:31Stephen J. Dubner?

  There you go.

• 23:32Speaker 01

  The power of poo.

• 23:33Speaker 02

  Freakonomics Radio is a co-production of WNYC, American Public Media, and Dubner Productions. This episode was produced by Chris Neary and mixed by David Herman. Our staff includes Colin Campbell, Susie Lechtenberg, and Borey Lam. Subscribe to this podcast on iTunes and you'll get the next episode in your sleep. You can find more audio at FreakonomicsRadio.com. And as always, if you want to read more about the hidden side of everything, go to Freakonomics.com.

• 24:18Stephen J. Dubner?

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• 24:48Stephen J. Dubner?

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• 25:27Speaker 05

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• 26:27Speaker 06

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