Parasites: The Good, the Bad, the Ugly with Dr Mark Donohoe

Parasites: The Good, the Bad, the Ugly with Dr Mark Donohoe

Are all parasites bad for us? Not necessarily.

Dr Mark Donohoe returns to FX Medicine to discuss all things parasites, from treatments using helminths, to why clinical trials using parasites might be flawed, why we should think twice before trying to “wipe out” a parasitic infection, and how some parasites have evolved alongside humans to be a benefit, rather than a detriment to our health.

Covered in this episode

[00:50] Welcoming back Dr Mark Donohoe
[01:57] Introducing today’s topic: parasites
[02:13] What is a parasite?
[04:06] The problem with microphobia
[09:00] Bacteriophages as therapy
[15:52] Pathogens, antibiotics and the immune response
[20:07] Dairy-derived probiotics
[21:35] Helicobacter pylori
[24:44] Tonsillectomies and the connection to paralytic polio
[28:14] Why we shouldn’t control for everything in a clinical trial
[32:25] Medicine is anti-evolutionary
[35:34] Building resilience
[40:45] Thanking Mark and closing remarks

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining us in the studio again today is Dr Mark Donohoe who earned his medical degree from Sydney Uni in 1980. He worked in the hospital system for three years before opening his own general practice on the New South Wales Central Coast.

This is when patient groups such as farmers who could not afford to be sick presented with complex illnesses which have been left undiagnosed and untreated by his peers. Mark attests that this is when his real medical education began. So he then delved into environmental medicine, nutritional medicine, and now, lifestyle medicine with fellowships in each modality.
Dr Donohoe is renowned for unravelling complex illnesses caused by toxic exposures, creating the first low exposure integrative hospital in Australia, and remains a staunch vanguard for patient advocacy and health.

Welcome back to FX Medicine, Mark. How are you going?

Mark: I'm great. I always sound better than I actually am when you give that beautiful introduction.

Andrew: That's rubbish. You have done a heck of a lot.

Now, today, Mark, we're going to be talking about the much-maligned parasite. We're going to be delving into when is a parasite a parasite, and when is it a therapy? Of course, you and I will go off onto our normal segue.

Mark: Yes, as we hope to.

Andrew: But let's start. I want to start with one that's always called a parasite. But it's not, it’s a facultative parasite. That is, the health of the patient is what governs whether it's bad or good or nothing, and that is Blastocystis hominis.

Mark: Even just one step before that, what's a parasite? A parasite is an organism that has a host that the parasite takes something from the host to the detriment of the host. We need to be clear before something is a parasite, rather than just a coexisting organism, it has to take something and it has to be some loss on the part of the host. The parasite-host relationship is a taking of the health energy, nutrients, or something from the host using it for its own resources at the expense of the host.

The question is for, say, Blastocystis hominis and for many of the parasites we'll talk about today is: when do they move from just being a co-occupant of the bowel, the nose, every inch of your body… When do they go from just being there - sometimes even being good for us - when do they move to that level where they are taking something where there is damage? Where there is harm to the host to the benefit of the parasite?

I think Blasto is a great place to start because a huge proportion of our population if you go and do the stool testing on them, you can find the DNA of Blastocystis. You can find the DNA of Dientamoeba fragilis. You can find it there in perfectly healthy people, and we don't go and treat those people. As doctors, we all know there are others who are very, very unwell who have Blastocystis in high numbers. When you treat the Blastocystis, you find that there is a clear improvement in the health of a person who you've just treated.

Andrew: Here's a question. So, I guess, firstly, I should amend what I said about a facultative parasite to a facultative pathogen. It's not always a pathogen.

Mark: Yes.

Andrew: My other thing is this. We see what we call a pathogen, a “target," and then we treat and the patient gets better. Is that treatment because it kills something else or eradicated something else along the way to what we thought was the target?

Mark: Yeah, it’s one of those great questions. This is part of the problem with clinical trials. When you try and control for every last detail, you may have controlled the very thing that was the benefit of what we actually do, and have got it out of the way. There is something about parasites. I think you've said this many times as well. Something about stress on a system that induces the host to respond appropriately and that balance between things that could be our enemy, but are not our enemy. That we convince them to stay in their little holes and do the right things by us, and we do the right things by them.

What turns a good guy bad? Why do they become that way? I think where the evidence is turning is we have what I've called “microbophobia.” We hate things that are small, that are invisible to us, that could cause harm, and so we become terrified of our own shadow. We clean everything. We have cesarean births. We treat every microbe as though it's just a bad piece of news about to happen, without ever paying attention until probably this last decade or two in the general medical community that the 99.9% of these are co-travellers with us. They're not bad. They're not good. They just make a living in an area of the gut. They do things that are good for us. We do things that are good for them, like feed them.

I even have a view of the world, which is what I call the “hard microbiome concept,” is we're only here for them. When you think in evolutionary terms of archaea, the bacteria, and the multicellular organisms, multicellular organisms were single-celled organisms that swallowed some bacteria and turned them into either mitochondrion or chloroplast and became multicellular. For what purpose? To hold bacteria and to hold viruses and to hold the other things to provide a safe living environment for them.

In that kind of hard concept, we are the constructs of the bacteria in evolutionary terms. We are also the homes for trillions and trillions and trillions of these bacteria, and trillions upon trillions more of the bacteriophages, and billions of the so-called parasites. Living in a healthy relationship where there are influxes, effluxes where: we get diarrhoea, we clear them out, we get more in when we eat more food. That was a thing mainly of the past.

Now, we have supermarkets. Very sterile. Food goes in with almost no bacterial content. If we do, it's a yogurt or something like that where we go out of our way to do something, or a bit of sauerkraut. We have got a gut which is no longer the gut of the swamps and having to eat fruits and berries off the ground, and pick things up and not be able to wash them. But evolution was making sense of that all the way through our evolutionary history. Parasites, bacteria, the fungi, candida and the like, they're all normal bugs. Given a normal environment, they will do their job and we live with them. They do things for us. We do things for them. That is not a parasite.

Andrew: As soon as you die, they return you to the Earth.

Mark: That is right. They're a recycling mechanism, but they're not parasites in that world. They're parasites when something happens to the host which turns…

So, something changes with, say, gut permeability. Molecules get across the gut and the immune system says, "Hey, you don't get there. You just don't get across there." That's where little wars break out and we see that as clinical illness. So I think we're talking about host response, barriers, and the fact that these bugs in the right environment are fine. This does not necessarily apply to Shigella, Salmonella. There are things which...

Andrew: Will kill you.

Mark: ...will actually kill you. I had that experience in '77. A little can of baked beans had a dent on the side, maybe a little hole in it. We thought, "It's only 10 cents. What could possibly go wrong?" Three years later...

Andrew: The famous words.

Mark: ...I knew everything about Shigella than a human needed to know, including the 20-kilogram weight loss. I don't doubt that we have our pathogens and things that we are best to avoid. But the rest of it, that odd balance of things that could harm us but don't, and if we provide environments for them, food for them, if we provide the barriers that keep them in their place, they're not parasites in any true sense of the word. They are simply cohabitants of our gastrointestinal tract, skin, and the like.

Andrew: You mentioned something a little while ago there, which I'd really love us to delve into. It's one of our little segues. That's bacteriophages. They're starting to poke their head up in the news of science as therapy.

Mark: I know. I have had patients now travel all the way to Russia to bacteriophage treatment centres with Crohn's disease, with really quite significant medical illness. Going there, people have intractable gastrointestinal disease but no known clear diagnosis. I've seen patients come back from there with treatments with bacteriophage potions. Now, I don't know the technicalities of it. It could be rubbish. This could be something other than bacteriophages but the bacteriophages, every bug has its bugs.

I'm sure there's going to be something that controls viruses as well, but the bacteriophage viruses do have a moderating effect on bacteria, especially in the gut. They outnumber the bacteria by hundreds to one. When we're looking down the line of, we have whatever it is 100 trillion cells and then there is 1000 trillion of...whatever those numbers are, as you get smaller, there's more and more of them. There was a line of...one of the great poets of the bacteria, the big bugs being bit by little bugs and so on ad infinitum. There seems to be no end to the molecular trail. It goes right back down to the smallest of viruses controlling bacteria, controlling other supposed pathogens, and I think there is a future in medicine for really taking a look at that.

The first thing that you see in the Western United States is, of course, people constructing artificial viruses to do that job, the bacteriophages that inject and control the bacteria. But the bacteriophages also have a control in terms of transmitting plasma and transmitting DNA material from one to another. There's a whole library of things yet to be discovered down below the microbiome. We keep on talking about the bacterial components. If there's a hundred times more bugs controlling those with almost infinite variety, then we have so much to learn about what goes on at that level of biological control.

Andrew: I have a concern about the cane toad example with bacteriophages. We think this is a therapy, and we have a cane toad experience in Australia whereby well-meaning scientists who thought they knew what it would eat and they didn't realise what it would do.

Mark: Oh, no. The hubris of science in medicine.

Andrew: That's right.

Mark: I love it.

Andrew: So, you know, where do we sit with this? A bacteriophage wants to invade bacteria. We can't choose whether it's got a smile on its dial or a frown, because how do you know what's "good" versus "bad" bacteria?

Mark: This is why this comes to one of my deeper fears. I'm a child of the Cold War rather than the real war. Everything done in Russia seems magical, and many of the things I think probably are not that greatly scientific but it comes from a grassroots of "we know something is happening here,” and they're prepared to do stuff, which I think is still 5 to 10 years out from what we can do in what we would regard as Orthodox Western research and medicine.

They are very quick to transfer it to the population, to do the human trial, maybe without a lot of the safety that could otherwise go around. I don't see this being used any time soon, but the idea that every little bug has its little bugs and its own microbiome, the microbiome of the bacteria - since they're single-cellular organisms - are probably the DNA of the bacteriophages that run outside their bodies rather than inside their bodies.

I am interested in it because so-called “incurable gut conditions” that I've seen people travel to Russia for, against my advice. I don't want Medicare coming and saying, "Stop sending people to Russia." I thought it was really tricky and really dodgy. But I have seen the people come back with the bacteriophage treatment thrilled that they had done it and moving on with their lives. Something profoundly changed in conditions that otherwise we'd be giving drugs for the rest of that person's life to try and control.

Andrew: Something measurably changed?

Mark: Something measurably changed. There's no Crohn's disease. Gone.

Andrew: As in TNF-alpha…

Mark: Yep, everything back to pristine state. But it's like you send them to Russia and then magic occurs and you see them back. What I don't see is...

Andrew: Could it be the plain food?

Mark: It could even be the food in Russia. My point is, when you send a person to a different country, they eat differently, they're in a clinic, which is different. The MacGuffin may well be: it’s not the bacteriophages, it’s actually the food. It's the diet. It's everything else that's going on there. Like most of Western medicine, we have very expensive bacteriophages or drugs that take the credit for it while something else did the groundwork.

I'm agnostic about it at the moment but, boy, talk about an exciting expansion of the Microbiome Project. The Microbiome Project is looking at the new organ within humans, which is the microbial environment. Not under our control. Different DNA. An organ within an organism that we never anticipated before. Then you think, “Okay, if there is now a whole separate dimension of the bacteriophages and the control of those, what are we missing? What is it about host responses of bacteria? Why do they proliferate? Why do lines drop off? How do we get better?” The cooperative idea there is, it's in everyone's interest to get on. If you're a human, a cow, a dog, a cat, or anything else, it's in everyone's interest to have a long-living organism which provides a safe home for all of those bugs.

Somehow they conspire together by a version of magic which I don't understand. I even have a view about the immune system, about the macrophages being very, very similar to the amoebian soil that we have an internal soil environment. A lot of what we call “immunity to fight off predators,” is in fact a cooperative system to allow for the right bacteria to live, and so we have that kind of gateways around the gastrointestinal tract where we've got signalling of “good guy/bad guy/don't know really which guy,” turn up the armaments, fire at the sky, “Oh back off don't pick a fight.”

So we've got communications going between the old soil microbes, if they're around there in sufficient numbers. We're keeping them at bay but not through an inflammatory process. How does that magic work? And I think we're just at the very beginning of that.

And other bugs that we consider, the parasites and the helminths and the like, they seem to be playing a very, very important part in that whole process.

Andrew: Let's delve into that, the helminths.

Mark: A great story.

Andrew: I guess specifically Trichuris suis, pig whipworm, and Necator americanus.

Mark: The pig whipworm is more popular because it doesn't live very long. It's always bad to kill a person with a parasite.

Andrew: But, when you look at trials, I've seen some positive outcomes, but I'm also aware of studies that have been stopped early because they just didn't meet any endpoints at all.

Mark: Well, also because they irritate the gut of the person and putting up with nausea, vomiting, or diarrhoea as a way of controlling your asthma or other immunological problems is always a bit tricky. If a drug did it, we'd say, "Oh, that's not a very good drug because it gives you diarrhoea." We still have...

Andrew: Now, that's really interesting. If it's a drug, that's okay. Antibiotic or Flagyl or something to give you - forgive me, Metronidazole - to give you diarrhoea is a side effect. But if it's a bug giving you...oh, it's bad. It's an infestation.

Mark: I still would say this: caution in medicine. When you're giving things that we hope don't normally invade people, you've got to be very bloody sure of the benefit and you also have to pay close attention to it. Nearly all the trials found that the pig whipworm is not too demanding on the gastrointestinal tract.

Andrew: It's 2,500 eggs, which might seem a lot but, when you consider that we're taking billions of bacteria, it's actually not that huge.

Mark: It's not that huge but they don't breed up very well in the gut, and they have a moderating effect on gut immunology and of inflammation. That triggers a response in the whole immune system which settles things like asthma. This concept that we have, that we used to have lots of bugs like that. It was right through evolutionary history that we have those bugs, and an immune system that utilised what the bugs brought to the table and the bacteria brought to the table and the candida brought to the table. The working out of that is what evolution is all about. This is a fait accompli. The survivors are the ones that learned to deal with these things pretty blood well, and we were those people who dealt with them pretty bloody well. We're the survivors and the progeny.

This is true parts of evolutionary history. If your response to simple parasites, worms was you were too weak to procreate, you didn't have much of a chance for your DNA. It's not like old-age problems, this is youngster problems. We are the cooperative group where the coop of organisms that we think of as human but is, in fact, layer after layer after layer of microbe. Every one of those microbes - well, not every one, there were some that are probably innocuous - but nearly every one of those microbes has the potential to do harm if it's out of control or in the wrong place.

So, even simple things like streptococci. Just bugs. Just normal bacteria normally found in the bowel. People who get lots and lots of tonsillitis and lots and lots of antibiotics and you breed up highly-resistant forms of streptococci, keep swallowing it, getting it onto the gut, and you have that streptococcal inflammatory gut type of disorder that happens that can send kids haywire in their behaviour.

Andrew: This is PANDAS.

Mark: This is the right bugs. They're fine if they're sticking up in the tonsils and you've never done the antibiotics. But if they make it down onto the gut or onto other organisms, all hell breaks loose. It's not even the right microbes, it’s the right microbes in the right place. Stuff that we're seeing with the mouth, the streptococcus salivarius. What do you need for protection? I'm very pleased to see that the probiotic concepts are moving into the nose, the mouth, the skin that we're starting to pay attention to more than just bifidobacteria, the lactobacilli. We're very fussy about all those TGA-approved bugs and yet the world is full of the wild bugs.

Andrew: That's right. This is one of the things that frustrates me. I get the caution because you don't want to be introducing a pathogen but there are so many more bugs out there. I think we've only got 14 species available to us in Australia. Most of them are dairy-derived, and there are so many more that are commensal in nature.

Mark: You can be sure that the majority of the world did not have dairy-derived probiotics.

Andrew: Yeah, that’s right.

Mark: It’s a convenient thing because certain bugs consume lactose. They take the lactose out and so the lactose-intolerant people are better off if they have fermented stuff. There are a whole lot of benefits of being Caucasian and having some of those lactases hanging around longer than the breast would have demanded. We tend to think in first-world areas, first-world solutions to what are effectively not first-world problems.

Andrew: If only we could go back and introduce Élie Metchnikoff to not just the Bulgarians and their kefir but also the Mediterranean diet perhaps and ask him to investigate the bacteria which were incorporated in there.

Mark: Going back through history, fermented foods was one way of living with foods without refrigeration. You had to be able to eat foods that have gone off and the bugs that were in the ferments have become our friends. You can make the case that all the humans in history that couldn't handle those bugs, they're not here to complain any longer. They're largely gone.

Andrew: We're getting off a little bit from parasites to pathogens, but I just wanted to sort of typically segue to a bacteria which is damned in its existence and that's Helicobacter pylori. I still see papers coming up saying that Helicobacter pylori may indeed protect against some oesophageal cancers, might be protective against even stroke and colon cancer. Do we get here into what Martin Blaser talks about, the missing microbes, that the problem is we've wiped out every break along the way? So therefore what we now call a pathogen can take hold and move into an area, as you say, where normally it did not reside. Now, it resides in another area and causes a problem.

Mark: It's not the job of bacteria to cause problems. All microbes want their host to be happy. Why? Because otherwise, an immune bomb of enormous force comes at them. For most microbes, their job is to not piss off the host. If they can not do that, they have a much, much better life. They don't have everything armed against them. We do have the Blastocystis, the single-celled parasites, where it looks like our ordinary method of dealing with them was with this immunoglobulin E histamine-releasing mast cell type of response.

If you've got those bugs, it does appear that there is something about histamine release, whether it's helminths or the single-cell organisms, where there may be a moderation of that. If our immune system's got a job to do and it's busy doing that job, it's not busy looking for pollens, grasses, dust mites, and dog hair or anything else. The moderation of it is enough of the bugs in the right place for us to keep control of, keeps our immune system busy in that area.

An immune system deprived of those bugs, deprived of just kids playing in the soil when they're young, getting their hands dirty, not having those antiseptic wipes their entire life or with an obsession to remove them from the dirt, grow up healthier. There is a value to giving an immune system that's looking for where the problems may arise, there’s a value to giving it something to play with, something to win the fights with, and not to become oversensitive, almost like a radar that, if it can't find its enemy close, it goes further, and further, and further away and starts to pick fights with pollens, grasses, and dust mite.

Andrew: See, these antiseptics have got a lot to answer for when they make TV ads that are so nonsensical.

Mark: Look, one part of that is television has nothing to do around the Christmas period and so there's forever an expert coming on to say, "We swabbed a table and found..."

Andrew: N=3.

Mark: "...40 different types of potentially fatal bugs." You can almost see what the ad is that's going to follow that story on the majority of new stories.

Andrew: Exactly.

Mark: You know who's coming next because that story is being put up.

Andrew: Product placement anyone?

Mark: Yes, I know. There are fatal bugs everywhere, and we are pretty good at getting low numbers out of our system very, very efficiently. We have tonsils. What people did forget for maybe 50 or 60 years there is that tonsillar lymphoid tissue in the upper part of the respiratory and gastrointestinal tract was really good in figuring out, "Wow, there's something that I don't really want to make have a home made anywhere down the way here." The tonsils, that great story of what was the cause of paralytic polio? 80% of it was tonsillectomy.

Andrew: What?

Mark: We saw polio breeding in the tonsils. So, yeah, the untold story of medicine. The reason tonsillectomy became almost impossible to get is that the final story was, if you took the tonsils out, within 30 days before or after exposure to polio, paralysis was five times more likely.

The paralytic side of polio was not purely the bug. It was that the tonsils were removed that allowed for the immune protection and the development of an appropriate response. What happened then is the gut had to do the job that the tonsils actually had. The tonsillar tissue was not rubbish. It was in fact an early warning system that said, "This is not a good bug. How do we develop a way around that?" There are two different parts of that poliovirus story, but a lot of the paralysis was iatrogenic. Doctors, once we found that out and accepted it in the 1950s and '60s, ran a mile from doing the tonsillectomies after that.

So we've controlled polio in a different way now. I mean we've had the polio vaccine and it's been effective. Polio is all but gone in the world. At that time, our fear that the tonsils were the breeding ground for polio was entirely misplaced. Doctors thought they were protecting people by whipping out the tonsils. There were predisposing them to a different version of polio which was far more likely to be paralytic. That is a good example of a story where we came to an agreement about how we would find out about pathogens that were coming. The upper respiratory tract was a good place for ENT surgeons to make a living especially back in the 1950s, '60s, and '70s. We took the approach that, if we could see the bug on the tonsils, then the tonsils must be the problem rather than the tonsils being the solution.

I think that happens in almost all areas of our dealings with immunology. The appendix was much the same thing. The idea that the appendix should be removed, and we should just get the appendix out of everybody and then the world would be safer for it. I think the story of the appendix is now much more that it's not a bad little bag to have of what used to be decent bugs. If you get raging diarrhoea, the appendix doesn't empty but everything else tends to go. And instead of faecal matter transplants, you have an appendix transplant. The bugs that were there could creep their way back out again and re-inoculate the gut.
Those lessons that we learned of microbophobia or fear of everything small is being changed by the Microbiome Project. When we're looking at that, we do still take the simplistic view of, "It's the bacteria, stupid," rather than, "It's the whole of the environment, the bacteriophages, the little tiny, tiny viruses, the bacteria of all their various sizes, the parasites that are single-cellular, like Blastocystis, and the helminths, the worms that were so very, very common as a moderator of our immunology, giving immune systems a job to do but not getting things out of control."

Andrew: Back to parasites, you spoke about asthma before. You've mentioned with the bacteriophages mainly with regards to Crohn's. I do recall...I think it was a company, and I think there was a big investment involved in this company with regards to the therapeutic use of a parasite for Crohn's and I remember the trial was stopped early because it didn't meet endpoint.

Mark: It was a negative outcome.

Andrew: In fact, it just failed. I'm mindful that a parasite has a gut and any gut is infested with bacteria. So parasites have their own microbiota.

Mark: Unless we breed them up without it.

Andrew: That's right. I wonder if you try and make something too clinical, as humans want to do, and you take out that which was actually a good thing in the first place.

Mark: You control for all variables. If you are thinking of a worm that way, a worm with its gut being a delivery method for bacteria that are in the worm's gut, then if you sterilise that worm, you're not adding that component. The trouble is, with the worms, with the helminthic therapy, we know that it works in things like asthma to some extent but we don't why or how.

The mechanisms, it's one of the dangers in medicine that you see something work, and you think, "I know why that works." And then you find 20 or 30 years later that that was not how it worked. It was in fact maybe, as you say, the microbiome of the worm in its own little dirty environment making its way in, the Schistosomiasis of the Africans, the different kind of whipworm and pinworm infections that we get, all of them bring their own bugs. If we take the bugs out of it, we're saying, "It's only the worm that is the critical factor," we may be neutering it before it has a possible chance of doing any good.

That happens when you see clinical outcomes, people with worms don't have asthma. Kids that got the worms don't have the same rates of asthma. That's epidemiology. That's observational. That's not a trial. When we try and clean things up for a trial, we control variables. You can trial too many variables and you progressively lose the benefit that you see in real life.

This happens in clinical trials at a much bigger level. We control for smoking. We control for everything. I never see the sick non-smoking, non-drinking, non-everything. Everything is controllable. That's not the patient that I see. The ability to take clinical trials and apply them to practice is a whole different podcast that we're going to have.

The obsessive control of variables is by analogy like the obsessive control of microbes. We want to cut them the microbes down. We tried to use antibiotics almost like it was a health food, that everything small is bad. It took 50 years to realise the downside of antibiotics and that we had lost nearly all of the benefit of antibiotics because we were unconstrained in our use of those antibiotics.

In reintroducing normality to the gut, we have a long path ahead of us. The long path is it's not just the probiotics that are approved by TGA here in Australia. It's not just a couple of living foods. It's a style of eating. It is the fact that we have nutrition-free foods where we're now claiming there is no need for us to have a stomach anymore. Why would we need a stomach? Apart from the digestion of food, there's a value to that acid, right?

That acid is not there just because it's really good at breaking down some components of food. That acid is a very good biological barrier that we are perpetually going to war with, with proton pump inhibitors, and we are trying to stop that acid because the stomach is just a terrible place for symptoms, and we pay very little attention to the consequences of not having a barrier for certain bacteria and opening up the gateways for problems to arise in an uncontrolled way.

I think personally that people are looking for what's the active ingredient of the parasite, is it something in the coat of it, is it something in the... I have a suspicion that we're going to come back to the answer that really it's kids playing in dirt, not in child care centres. One thing I will say is, if you're going to develop...

Andrew: Kids playing in dirt on a farm.

Mark: Yeah, playing in dirt on a farm with stuff, where poo is around the place, where animals have been there, allowing kids that ability to get out and get themselves a bit of diarrhoea every so often, a bit of vomiting every so often. Allow them to run into the vicissitudes of life and see what happens.

Right behind this, there is a terrifying question, which I ask myself every day: medicine is antievolutionary. What do I mean by that? Medicine tries to make every life...it's survival of the richest, not survival of the strongest. What will be pointed out is that, in days bygone, we had a 30% infant mortality rate. A third of all kids that were ever born died and so are pining for the fjords, pining for the fjords that had lots of parasites in them. There was a lot of dying of babies that used to happen that no longer happens. We save every child. Whether they're evolutionarily fit or not, every child is sacred. We have to deal with the fact that Western orthodox medicine is by its nature antievolutionary yet, in deep biology, we believe that evolution is the only selection force that makes any sense about how we progress as a species.

Having taken natural evolution out, we are now responsible for every detail of the child's life and growing up to adulthood. I think what's happened is the success in perinatal mortality has meant that there is maybe a third of the population that would not have made it in the past that now does and we are looking after and spending more and more of our resources with that.

We wouldn't have it any other way. Nobody wants to ever lose a child, but it's the corner we're painting ourselves into, that you pay thousands of dollars for in vitro fertilisation or assisted fertility. You get children who could not have made it, born at 26 and 24 weeks. All of that is now just a challenge to medicine to say, "We can get survival out of that." One day we have to deal with the fact that we are breeding a human race that is not evolutionary well-protected, and so we have to control every aspect of the environment that those humans are in.

That's a male way of thinking about it. We will control the world. We'll control global warming. The technology will be the answer to it. I have the suspicion that, when we get to the wisdom of time and it may 50 or 100 years down the line, we'll be saying, "You know what? It was a value to the way that nature provided the soil microbes, provided that balance. Food was food rather than food-like substances, and that the parasites and the worms and the microbes and the bacteriophages, that it's a complexity that may be beyond us. One day we might have to just deal with the fact that we can't control every aspect of the world. We can't go giving parasites in a particular way. We need to let our natural process go back and occur again and then deal with the consequences of that."

Andrew: One of my concerns with helminths as therapy is, by the time the patient seeks that therapy, they're in such an exhaustive state that their terrain is so rundown. Their gut is so bereft of health that the parasite is going to not have any breaks.

Mark: Yes.

Andrew: What could even be studied in a world population to have benefit, you give it to somebody that has no resilience, and you've got a crisis on your hands. I always default to, we want to kill things. We want to put things in their place. We want to do things to them. But it's like you have said, and you have indeed educated me on so many occasions, that we've got to think about what is the function of the symptoms for those patients, for that patient, and to help rebuild that resilience is a naturopathic axiom of nourish.

Mark: It is not a medical concept, resilience. We think of resilience as what you rebuild after we've done medical treatment and after surgery. We think of that convalescence as, "Oh, that's resilience. It's kind of on the side." I think you are absolutely right that the change in mindset is, how do we build resilience into young people? It's not a technology answer. Loving environments are an important part. Contact with skin is an important part. Music appears to be an important part.

Andrew: Getting out in nature.

Mark: Culture. Getting out in nature. Playing seems to be an important part. All of them don't come down to a medical treatment, but we are exploring those, music therapy, things along those lines. I do agree with you that host response, that is tricky to get right so that if we leave it too late, we're left with medical treatments because they're an emergency. Just as you're falling off the cliff, you try and catch the person before they actually fall. You've left it there; it's already too late.

What we need to do is bring things back to childhood and early life, like breastfeeding. Vaginal birth where possible. Start the microbes off in a good way. Allow for nature to do its job in those first five years of life. My absolute view is those first five years are critical. If you can get those right and you can start the person out on that path, resilience is a natural outcome of that. There is no failure at that first level. If you keep doing the cesareans, not breastfeeding, if we keep on doing things with antibiotics unnecessarily, then what we do is we breed a person who is too close to the edge to not need medicine in the future.

Andrew: The caveat is that there are certain times when it's medically necessary to intervene, and you just have to rebuild. We should be favouring these fermented foods. I'm so blessed in that I was a lover of sauerkraut early on. I just feel so lucky. And yogurt. I've always loved yogurt. My kids don't. In fact, one of them is only just getting into liking yogurt now that he's 22.

I also just wanted to make the point that there are...as we discussed with bacteria, there are some that are just plain pathogenic. Like, for instance, threadworms in humans, pinworms, Enterobius vermicularis. There is only one trial that I found, an Italian trial where it was used as a therapy. Other than that, it's always bad.

When investigating helminths therapy, you've got to be very cautious about the resilience of the patient and the terrain of the patient. We've got to be very cautious about the quality of any therapy that might be advocated.

Mark: That's what I'm saying. Kids, don't do this at home. This is not advice to move into helminth therapy. We're not talking about that. It's advice to say have a think about whether the bugs, the Blastocystis or the Dientamoeba or the worms, have a step back and say, "Are they doing harm? Do we need to attack these monsters in the gut or can we leave them alone?" Can a person build resilience? Can their asthma be controlled by those types of things? Not to go and infect them with something that we think and hope might work but by allowing them to participate in play and the normal things that allow their immune system to do that work along the way.

It's way short of primetime use of these bugs, of these helminths, of these treatments, but the cautionary tale is, they're on the way. We're going to understand them and what we're going to say is maybe back off a little bit with what you think of as a pathogen and start to think of it as: is there a way of modifying this so that their pathogen is not pathogenic? That the host is well, that the naturopathic principles of building resilience allow for a better relationship between the host and their bugs.

Andrew: Dr Mark Donohue, as always, you give us salient advice. You give us a balanced view of the positives and the negatives and the cautions that we have to be aware of when we're thinking of various therapies for our patients.

Remember that you can listen to Dr Mark Donohue on our sister podcast, FX Omics, available on iTunes. Thank you once again for taking us through today some of the theories around parasitic therapy. Thanks so much.

Mark: It's been a pleasure as usual.

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.

Other podcasts with Mark include

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