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?

SAMUEL COURTAULD TRUST
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The monochrome set

In Pieter Bruegel’s hands, even black and white paintings can be full of colour.

Grisailles – monochrome images usually painted in shades of grey and white – have a long tradition. Early examples appeared in the 14th century as miniatures or manuscript illuminations and then later on the outside of the folding panels of altarpieces, where they imitated sepulchre statues and offered a stark contrast to the bright colour of the paintings inside. With their minimal palette, grisailles also offered painters a chance both to show off their skill and to add their bit to the age-old artistic debate about paragone: which was superior – sculpture, with its ability to show a figure in three dimensions, or painting, with its powers of illusion? By pretending to be sculpture, grisailles could better it.

The first artist to paint grisailles as independent works for private enjoyment and contemplation was the Netherlander Pieter Bruegel the Elder (circa 1525-69), whose folk scenes of peasants carousing or of hunters in a snowy landscape have long been staples of art’s quotidian, earthy strand. Only about 40 works by him are now known and of those, just three are grisailles (not a term he would have recognised; he referred to the pictures simply as “painted in black and white”). This trio of survivors has been reunited for the first time, at the Courtauld Gallery, with an accompanying selection of copies and engravings – a mere ten pictures in all – for a fascinating one-room exhibition.

The grisailles show a deeper and more intellectual artist than the sometimes slapstick figure who would dress as a peasant in order to gatecrash weddings in the Brabant countryside and record the drunken and playful goings-on in his pictures. They reflect the position of the Low Countries in Bruegel’s time, caught between the Catholicism of their Spanish overlords and the emerging Protestantism that had been sparked by Martin Luther only eight years before Bruegel’s birth. These tensions soon erupted in the Eighty Years War.

Of the three paintings, two show religious subjects – The Death of the Virgin (1562-65) and Christ and the Woman Taken in Adultery (1565) – and one is a scene that would have been familiar in the streets around him, Three Soldiers (1568). This last, lent by the Frick Collection in New York, shows a drummer, a piper and a standard-bearer in the elaborately slashed uniforms of German Landsknechte mercenaries. Such groupings featured often in German prints and Bruegel’s small picture is a clever visual game: painting could imitate not only sculpture, but prints, too. What’s more, the gorgeously coloured uniforms (mercenaries were exempt from the sumptuary laws that restricted clothing to sedate colours) could be shown to be just as arresting even in black and white.

If this is a painting about painting, the ­religious works have, it seems, added layers of meaning – although it is always difficult with Bruegel to work out what that meaning is and how personal it might be. The Courtauld’s Christ and the Woman Taken in Adultery shows Jesus stooping in front of the Pharisees and saving the accused woman from stoning by writing in the dust, “He that is without sin among you, let him first cast a stone at her.” That he spells out the words in Dutch rather than Hebrew, which was more usual in other images of the scene (and which he uses on the tunic of one of the learned men observing the mute play), suggests that this picture – a plea for clemency – was intended to serve as a call for religious tolerance amid mounting sectarian antagonism. While the gaping faces of the onlookers recall those of Hieronymus Bosch, the flickering calligraphic touches and passages of great delicacy are all his own.

The picture stayed with Bruegel until his death, so it had a personal meaning for him; more than 20 copies were subsequently made. Included in the exhibition are the copies painted by his sons, Jan and Pieter the Younger (a coloured version), as well as the earliest known print after it, from 1579, by Pieter Perret, which shows some of the detail in the crowd around the central figures that has been lost in the discoloured panel.

If the sombre tones of grisaille are suited to the pared-down faith advocated by Luther, the death of the Virgin was a familiar topic in Catholic and Orthodox iconography. Bruegel’s picture, from Upton House in Warwickshire, depicts an episode that doesn’t actually appear in the Bible. A group of Apostles and mourners has gathered around the Virgin’s bed, the scene lit by the heavenly light emanating from the dying woman and the five flames from the candles and the hearth that correspond to the five wounds suffered by her son on the cross. Domestic items litter the room – a slice of orange, slippers, a dozing cat – and there is a sleeping attendant, unaware of the miracle of Assumption that will shortly unfold. Here is a moving nocturne in which the mysteries of religion emerge from and disappear back into the shadows.

While Bruegel’s peasant works display a delight in physical pleasure, these three bravura works, painted for humanist connoisseurs and for himself, portray the sober, spiritual concerns that come to the fore once the last drop has been drunk. 

The exhibition runs until 8 May. For more details, go to: courtauld.ac.uk

Michael Prodger is an Assistant Editor at the New Statesman. He is an art historian, Senior Research Fellow at the University of Buckingham, and a former literary editor.

This article first appeared in the 11 January 2016 issue of the New Statesman, The legacy of Europe's worst battle