The Antibiotic Era: Reform, Resistance, and the Pursuit of a Rational Therapeutics
By Scott H. Podolsky | Johns Hopkins University Press | $72
A young man lies in a hospital bed surrounded by his family; the mood is subdued and the faces of his loved ones betray the terrible gravity of the situation. His body, weakened by infection, has been ravaged by bacteria; the doctors announce there is nothing more they can do. Not too long ago a simple course of antibiotics would have been enough to save his life; but the bacteria have been fighting back. The never-ending arms race between human and pathogen has led to this strain being resistant to all the antibiotics medicine possesses.
This is not a vision of the present day, as the constant bombardment of the shrill media machine and its obsession with “superbugs” may have you believing. Nor is it some grim dystopian future in which we have lost our battle for self-preservation. This unfortunate young man lived in the 1950s. And his experience was but the leading edge of the rise of antibiotic resistance.
Over the following years it wouldn’t take long for researchers and clinicians to link antibiotic resistance to antibiotic exposure. The indiscriminate or haphazard prescription of antibiotics, they found, led to unnecessary contact with microbes, selectively pressuring them to develop resistance to these very substances.
As these insights and misgivings grew, other forces were also at work. In the years following the second world war the antibiotic was the pin-up of the therapeutic world. It was the wonder drug, not only for a populace desiring an improved health system to match its rising standard of living but also for drug companies that saw the next great bonanza in their midst. But antibiotics were developed and released in what was effectively a regulatory vacuum, and the exploitation of this fact would prove to be the spark for the coming conflagration.
While the US Food and Drug Administration had responsibility for deciding on the safety of drugs, it did not adjudicate on their efficacy. It is this regulatory gap that the drug companies came to exploit. As patents on antibiotics began to expire, they used a multitude of tactics to maintain their monopolies, including aggressive marketing, free samples, “education” campaigns for practitioners, and sponsored “scientific” discourse. But their most effective act was to create proprietary fixed-dose combination therapeutics.
By taking an antibiotic close to the expiry of its patent and combining it with another patented antibiotic, a company could release a new product, with a new patent. These new therapeutics often offered no advantage over their individual components, and could even be less desirable because of toxicity or because they drove increased antibiotic resistance. In the absence of a regulatory body with the power and willingness to investigate medicinal efficacy, such therapeutics could thrive.
But these developments didn’t go unnoticed. A growing body of researchers and practitioners found the scattergun use of antibiotics a cause for alarm. These individuals soon began to coalesce into an identifiable group. The drug industry’s attempts to establish itself as the reliable and appropriate educator of frontline practitioners was beginning to be challenged, and soon the battlelines would be drawn. The age of the antibiotic reformer had arrived.
It is into this developing drama that Scott Podolsky delves in The Antibiotic Era. Podolsky is an American physician, academic and medical historian, and his book concentrates on antibiotic reformers in the United States. But that focus does not present a particular problem for readers in other countries, given the size and importance of the American pharmaceutical industry and the far-reaching consequences of its decisions.
In addition to antibiotic resistance, Podolsky also looks at related issues including the use of aggressive product marketing, the development of the controlled clinical trial, and the role of government in delineating what could and could not (or should and should not) be available to practitioners. He vividly explores the personalities of the reformers and their opponents – the most prominent being Max Finland, the man who would become the rallying point and mouthpiece of the reform movement and who is a justifiable object of the author’s admiration – and describes conflicts both internal and external.
Podolsky’s use of language is nothing short of sublime, and he displays an effortlessly dry wit and a willingness to dazzle through the twists and turns of the narrative. But his liberal use of the vocabulary of a lexicographer can at times, without intent, approach the baffling. This leads me to the closest I can come to criticism of this book. The Antibiotic Era is unashamedly written for medical historians and members of the medical profession. This is not in itself a cause of criticism – not every history needs to be for everyone – but it does mean it is not an entry-level book for those wishing to learn more about antibiotic reform and related subjects. If you aren’t closely associated with the field you might want to have a device on hand, as I did, to Google the occasional reference.
Podolsky makes no apologies for steering away from the experience of patients and their families, which lies outside the scope of his topic. The lack of a patient’s perspective, coupled with the sometimes technical language can, at times, leave the impression of an analytical and even cold approach to the subject matter. But ultimately this is a minor criticism of what is a supremely well-researched historical narrative.
The extent of that research became evident not long after I had settled myself down to the challenge of tackling a not insubstantial book of 300 pages. I quickly discovered that nearly half of the text is dedicated to “notes.” These include straight bibliographical references, but also substantial anecdotes, letters, scientific data and other pieces of information, which, while interesting, didn’t fit in, or were too large for, the main narrative. The temptation might be to ignore this material (flipping back and forth can feel tedious), but I’d encourage you not to do so. The notes can be just as insightful, informative and amusing as anything in the main text and it is well worth the trouble of including them in any attempt to tackle The Antibiotic Era. They are a testament to Podolsky’s many hours of meticulous research, using historical collections, journals, congressional records, advertisements, personal letters and interviews. He clearly approached this book with the passion of a labour of love.
While the actions of equally passionate reformers may have come too late for the young man and his family I introduced at the beginning of this review, their actions helped prevent this same scenario from occurring countless times more. Through agitation, confrontation, persuasion and legislation the reformers played a critical role in shaping the medical landscape we know today. Such a tale of rationality in the face of manipulation and misinformation and the importance of those who would counteract such forces remains apt today as we see the rise in influence of movements such as the anti-vaccine lobby.
Scott Podolsky has produced a meticulous, intelligent and pointed lesson from history, with relevance today. The Antibiotic Era should be mandatory reading for those in the medical profession and is well worth the steep learning curve for those with an interest in the field but from a different background. •