The Power of Poop

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

William KOSTOPOULOS: I had a lanrynxal 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.

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

KOSTOPOULOS: This persisted for about three-and-a-half, four years after that. You know, pain, optic neuritis–they’d done CAT scans, they’d done all sorts of things. And then one particular doctor decided to get an MRI done. In the MRI after the optic neuritis, the optic nerve was playing up , you know, I was going all cloudy and couldn’t see properly out of my left eye. That 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 you can forget this guy, he’s going nowhere.

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

KOSTOPOULOS: I came to know Dr. Borody through my wife. She used to cut his hair because she owned a salon in Five Dock, and that’s how I got to know Dr. Borody.

DUBNER: And why did you go to Dr. Borody for treatment?

KOSTOPOULOS: Because he was very, very concerned about my health. He’s known me for years through my wife, and when he saw me get ill he was very, very shattered and very concerned.

Dr. Thomas Borody 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 Borody isn’t your typical gastroenterologist. He is, to put it mildly, a bit of a medical maverick. The treatment he tried on William Kostopoulos was something that most of us — something that even most doctors — would find unusual, and perhaps unsettling. But then, it apparently worked.

KOSTOPOULOS: It wasn’t an overnight occurrence where 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.

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.

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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 Borody 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.

Thomas BORODY: 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 percent human and 90 percent poo.

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 who’s ill? That’s what Borody did for William Kostopoulos’s MS. He performed a “fecal transplant.”

BORODY: When the stool is infected with a bug, when we changed 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 that’s got infected flora, that infected flora may be cured by that single implantation.

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. Borody has been performing fecal transplants for more than 20 years. He began by treating diarrhea and constipation.

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

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. Borody himself has treated a few Parkinson’s patients by focusing on fecal bacteria — successfully, he claims — and he is currently setting up a medical trial to prove that he’s right. It should be said that Borody’s work is not being greeted with universal enthusiasm by his fellow physicians. Which, in the scope of medical history, is pretty typical. Borody points to the case of Barry Marshall, a fellow Australian gastroenterologist. Marshall became convinced 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. 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.

BORODY: 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 that initially criticized Barry Marshall, and initially Louis Pasteur was criticized like this, and so was Edward Jenner with immunization for smallpox. So I don’t expect anything different, but even now my colleagues would avoid talking about this or meeting me at conferences, although this is changing. I’ve just had an invitation to speak at an international conference about fecal transplantation, that’s state of the art. So I think we might be turning a new leaf, and I think we should, with poo especially.

One thing that might help Borody turn a new leaf is a catchy name. I tried to help him come up with something, but he was way ahead of me.

DUBNER: So can’t you call it flora therapy? That just sounds like some rose petals being sprinkled about?

BORODY: 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 transpoosion…” So you know, we could use all terminology.

There you go: a transpoosion. Coming up: The transpoosion takes root in America, too.

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American researchers are looking into the medical value of poop as well.  At University of Minnesota, Alex Khoruts 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 transpoosion from healthy, trim people.

DUBNER: Most people when they think of human waste, they just think, you know, “ Eeewww.”  What do you think of when you think of human waste?

KHORUTS: Well, part of me has not overcome that feeling. I think it’s universal. It’s evolutionarily put in there; we were 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. It’s essentially like the elephant in the room for a gastroenterologist.  We talk about all the other parts of the digestive tract, but we’re so ignorant about this component, that most gastroenterologists and other scientists know very little about it. So our level of knowledge hardly exceeds that of a fifth grader who just says exactly as you said, “Eeewww.”

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”?

KHORUTS: I think of it as a microbial organ. So it’s just like an organ, anywhere else in your body–

DUBNER: –but we’re talking about poop.

KHORUTS: We’re talking about poop, yes. Poop is just what we see. It’s a little more complex than that inside, but 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.

DUBNER: Now, talk to me, 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?

KHORUTS: Fecal transplantation actually is not something completely novel. In the ’50s, 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 percent. So, in the ’50s, people decided “Well, we’re probably messing up bacteria inside, and what will happen if we just infuse them back? We’ll take some fecal material from a normal, healthy donor and homogenize it with saline, and infuse it then as an enema.” And in fact, they 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, an infection of clostridium difficile. This pathogen has been getting smarter and smarter with time, and has reached truly epidemic proportions. We treat the infection with other antibiotics, usually more 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 grafted 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, had done a true transplant.

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

KHORUTS: 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 the laboratory by themselves. So it’s a very complex world, until the development of latest DNA technologies and computational techniques, it was inaccessible to study.

Like Borody, Khoruts 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.

KHORUTS: 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. 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. “Boy, I wish I was in that field!”  And it just so happened that 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.

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 collectively been 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 turn conventional wisdom on its ear. All it takes is a couple of gutsy investigators willing to go to a dark place.

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 Khoruts and Thomas Borody —  turns out to be a health breakthrough, rather than a heath hazard? Borody can’t say with 100% certainty that poop is why his MS patient William Kostopoulos got his life back, but, well, he did get his life back.

DUBNER: Did you ever give Dr. Borody a gift of any sort to thank him?

KOSTOPOULOS: No, actually, I’ve never done that. I’ve got to give him something–I’ve never done that.

DUBNER: I’m not saying you have to, I’m just asking a question.

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

DUBNER: You know what might be nice? Maybe you could install some new toilet paper rolls in his house, some gold-plated toilet paper dispensers.

KOSTOPOULOS: I might get some toilet paper printed.

DUBNER: Oh there you go.

KOSTOPOULOS: Just especially for him.

DUBNER: There you go.

KOSTOPOULOS: “The power of poo.”

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Freakonomics Radio is a coproduction of WNYC, American Public Media and Dubner Productions. This episode was produced by Chris Neary and mixed by David Herman. Our staff includes Collin Campbell, Suzie Lechtenberg, and Bourree 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.