England's chief medical officer on why the drugs don't work

Large-scale resistance to antibiotics is inevitable, yet new antibacterials aren't emerging. Why?

The Drugs Don’t Work: a Global Threat
Sally C Davies, with Jonathan Grant and Mike Catchpole
Penguin Specials, 112pp, £3.99

Professor Dame Sally Davies, England’s chief medical officer, likens the impending crisis in antimicrobial drug resistance to global warming. In both instances scientists foresee a problem and can offer solutions. In neither case is our response anywhere near sharp enough, Davies fears. Acting on antibiotic resistance should be the easier of the two; no one has a vested interest in denying the risk. Why then are we stumbling towards a selfmade but preventable calamity?

Alexander Fleming is credited with discovering antibiotics. In the summer of 1928, while working at St Mary’s hospital in London, he went on holiday and left an open plate of bacteria behind. Returning to work, he found a fungus growing on the plate that had killed the bacteria with a chemical that he named penicillin. In 1930s Oxford, Howard Florey and Ernst Chain produced enough penicillin to prove its healing ability. The penicillin production programme that followed during the Second World War is a classic tale of ingenuity under adversity. By engaging American pharmaceutical companies, the Allies were able to cure soldiers of otherwise fatally infected wounds.

Bugs create chemicals to kill other bugs as part of an aeons-old microbial arms race, so drug-hunters turned to soil microbes to help fight a range of diseases. Streptomycin, discovered in America in 1943, even cured tuberculosis, one of mankind’s greatest afflictions. Today, however, roughly a third of the world’s population still carries TB. Of the nearly 9,000 cases reported in the UK in 2011 hundreds of sufferers were resistant to at least one drug. Half a dozen cases carried incurable, “extensively drug-resistant” strains of TB. Cholera, leprosy, typhoid fever and syphilis all remain global scourges. Just last year several people in Edinburgh died after inhaling legionnaire’s disease-causing bacteria. Dozens of Germans died in 2011 after eating beansprouts contaminated with E coli.

Luckily, for now at least, we can still treat most bacterial infections, but some bacterial cells can yield over a billion progeny in just 24 hours. Genetic mutations stimulating drug resistance are inevitable. Cases of penicillin resistance appeared almost immediately: methicillin, a more stable derivative of penicillin, enjoyed only a few years of success before resistance emerged. Methicillin-resistant Staphylococcus aureus (MRSA) now kills hundreds in British hospitals every year.

Yet new antibacterials aren’t emerging. The reasons for this are primarily economic. Antimicrobial agents are usually given in shortterm doses. Compare that to statins, taken by affluent westerners with high cholesterol over decades. Most antibiotics are also off-patent, which has driven prices down. The estimated $1bn it costs to develop a drug inflates the cost of new medicines. Cash-strapped health services will use cheaper, old drugs until their utility is all but gone.

Davies fears that time might come quickly. Resistance genes are flourishing out there and bacteria are remarkably happy to share their genes. The widespread imprudent use of antibiotics has created perfect conditions to select those resistance genes and global air travel can carry resistant bugs around the world in hours.

Davies offers possible solutions. Fifteen years ago the pharmaceutical industry had largely abandoned diseases of the poor – malaria, tuberculosis, sleeping sickness, bilharzia and so on. An anti-sleeping sickness drug, called eflornithine, was even about to be withdrawn because sufferers couldn’t pay for it. When eflornithine was shown to prevent unwanted hair growth, however, pharmaceutical companies fell over themselves to produce it. Economics dictated that a drug could be made to “treat” unwanted facial hair but not to save lives. New models were needed to combat diseases of the poor. Groups such as the Medicines for Malaria Venture and Drugs for Neglected Diseases Initiative emerged to help promote drug development. A decade on, the first new drugs are poised to appear. The pharmaceutical industry itself, though, is in crisis and shedding staff at an alarming rate.

If a pestilential Armageddon really is upon us, a cynical company might gamble on huge profits, getting new antimicrobials ready for when the competition fails. But the economic models won’t shift until the evidence becomes overwhelming. Davies also talks of incentivisation – a £50m prize to develop a new antibiotic, for instance. Given development costs, $1bn would be more realistic. Yet even that’s a snip compared to the taxpayers’ bank bailouts. Surely saving life trumps life savings. Whatever it takes, though, action is needed now. The big pharmaceutical companies continue to abandon their anti-infective programmes and with them goes the expertise and capacity that will be needed when the crisis hits.

Michael Barrett is Professor of Biochemical Parasitology at the University of Glasgow

Who decides which drugs are made, and which ones we have access to? Image: Getty

This article first appeared in the 30 October 2013 issue of the New Statesman, Should you bother to vote?

Photo: LYNSEY ADDARIO
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What Happened reveals Hillary Clinton as a smart thinker – unlike the man who beat her

Those asking why she blames everyone but herself for Donald Trump clearly haven't read the book.

Hillary Clinton is smug, entitled, dislikeable, hawkish, boring. She was unable to beat a terrible Republican presidential candidate. Why doesn’t she just shut up and sod off? Bernie would have won, you know. Sexism? There’s no sexism in opposing someone who left Libya a mess and voted for the Iraq War. Also, she had slaves.

This is a small sample of the reactions I’ve had since tweeting that I was reading Clinton’s memoir of the 2016 campaign. This is one of those books that comes enveloped in a raincloud of received opinion. We knew the right hated Clinton – they’ve spent three decades furious that she wanted to keep her maiden name and trying to implicate her in a murder, without ever quite deciding which of those two crimes was worse. But the populist candidacy of Bernie Sanders provoked a wave of backlash from the left, too. You now find people who would happily go to sleep in a nest made out of copies of Manufacturing Consent mouthing hoary Fox News talking points against her.

One of the recurrent strains of left-wing criticism is that Clinton should apologise for losing to Trump – or perhaps even for thinking that she could beat him in the first place. Why does she blame everyone but herself?

Perhaps these people haven’t read the book, because it’s full of admissions of error. Using a private email server was a “boneheaded mistake”; there was a “fundamental mismatch” between her managerial approach to politics and the mood of the country; giving speeches to Wall Street is “on me”; millions of people “just didn’t like me… there’s no getting round it”.

Ultimately, though, she argues that it was a “campaign that had both great strengths and real weaknesses – just like every campaign in history”. This appears to be what has infuriated people, and it’s hard not to detect a tinge of sexist ageism (bore off, grandma, your time has passed). Those who demand only grovelling from the book clearly don’t care about finding lessons for future candidates: if the problem was Hillary and Hillary alone, that’s solved. She’s not running in 2020.

Clinton marshals a respectable battalion of defences. Historically, it is very unusual for an American political party to win three elections in a row. The Democrats (like Labour in Britain) have longstanding problems with white working-class voters outside the big cities. Facebook was flooded with fake news, such as the story that the Pope had endorsed Trump. And besides, Clinton did win three million more votes than her Republican rival.

Added to which, it is now hard to deny that Russia interfered heavily in the US election, with Trump’s approval – “Russia, if you’re listening, I hope you’re able to find the 30,000 emails that are missing,” he told a press conference in July 2016 – and perhaps even with the active collusion of his campaign. The next Democratic candidate will have to reckon with all this.

The election outcome would have been different if just 40,000 voters in three key swing states had flipped, so there are dozens of potential culprits for Clinton’s loss. But perhaps one of the reasons that many in the US media have been so hostile to the book is that it paints them as such villains. Even now, it is common to hear that Clinton “didn’t have an economic message”, when a better criticism is that no one got to hear it.

In their mission not to be accused of “elite bias”, the media desperately hunted for bad things to say about Clinton, when none of her offences came close to the gravity of a totally unqualified, unstable man with no government experience going on a year-long bender of saying mad shit and boasting about sexual assault. In both the primary against Sanders and the general election, she was treated as the obvious next president, and held to a different standard. (Incidentally, there is surprisingly little criticism of Sanders in here; she credits him with helping to write her policy platform.)

The book is at its best when it reflects on gender, a subject which has interested Clinton for decades. She calculates that she spent 600 hours during the campaign having her hair and make-up done, as “the few times I’ve gone out in public without make-up, it’s made the news”. She writes about the women she met who were excited to vote for a female president for the first time. She mentions the Facebook group Pantsuit Nation, where 3.8 million people cheered on her candidacy. (Tellingly, the group was invite-only.)

Yet Clinton was never allowed to be a trailblazer in the way that Barack Obama was. That must be attributed to the belief, common on the left and right, that whiteness and wealth cancel out any discrimination that a woman might otherwise suffer: pure sexism doesn’t exist.

The narrative of the US election is that Clinton was deeply unpopular, and while that’s true, so was Trump. But where were the interviews with the 94 per cent of African-American women who voted for her, compared with the tales of white rage in Appalachia? “The press coverage and political analysis since the election has taken as a given that ‘real America’ is full of middle-aged white men who wear hard hats and work on assembly lines – or did until Obama ruined everything,” she writes.

Clinton faces the uncomfortable fact that whites who feel a sense of “loss” are more attracted by Trump’s message than Americans with objectively worse material conditions who feel life might get better. That is an opportunity for the left, and a challenge: many of those Trump voters aren’t opposed to benefits per se, just the idea they might go to the undeserving. Universal healthcare will be a hard sell if it is deemed to be exploited by, say, undocumented immigrants.

Yes, What Happened is occasionally ridiculous. There’s a section on “alternate nostril breathing” as a relaxation technique that a kinder editor would have cut. The frequent references to her Methodism will seem strange to a British audience. The inspirational stories of the people she meets on the campaign trail can feel a little schmaltzy. But it reveals its author as a prodigious reader, a smart thinker and a crafter of entire sentences. Unlike the man who beat her. 

What Happened
Hillary Clinton
Simon & Schuster, 494pp, £20

Helen Lewis is deputy editor of the New Statesman. She has presented BBC Radio 4’s Week in Westminster and is a regular panellist on BBC1’s Sunday Politics.

This article first appeared in the 21 September 2017 issue of the New Statesman, The revenge of the left