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?

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The Last Wolf: Robert Winder's book examines the elusive concept of Englishness

If English national character is so hard to pin down, could this mean there is no such thing any more?

Is there anything more tiresome than debating the essence of “Englishness” – or any other national identity, come to that? Millions of words must have been spilt on this fruitless quest over the past century, generating gigatonnes of wind that could have been usefully harvested for energy. Each time, no “essence” is to be found, and everyone goes back to the beginning and starts again.

That’s how it used to be, anyway. More recently, in the wake of the Brexit vote and the divisions it has laid bare, the debate about who “we” are has become fraught and urgent. England, and Britain more widely, is hardly alone in its soul-searching. Arguments about belonging, culture, nationhood and identity are flooding across the Western world – and beyond – because people are increasingly unsure about who or where they are. The sweeping changes unleashed by hypercapitalism, technological change and unprecedented levels of migration are making rootlessness the norm, and the more people feel rootless the more they want to know where they belong and where they come from.

British politicians often respond to this by attempting to formulate some notion of our collective “values”. Here’s who we are, all 65 million of us, they say, and then proceed to read out a list of uniquely “British” things that only “British” people do, like valuing democracy, being tolerant with each other and standing in queues politely. These attempts at top-down unity are always failures, largely because, with the possible exception of the queuing, all the “values” asserted are pretty much universal. There’s nothing uniquely “British” about valuing the rule of law or freedom of speech (regularly clamping down on freedom of speech is a more reliably British virtue, if history is anything to go by). The failure of anyone to produce a list of “values” that are uniquely British – or English, or Welsh, or Scottish – suggests that they don’t exist. The island is just too teeming, diverse and disconnected now for much to be held in common at all.

So what, if anything, might define that elusive “Englishness”, the subject of Robert Winder’s new book? Cultural quirks, perhaps? I can confidently assert that the English know how to make a good cup of strong tea better than anyone else on earth (with the possible exception of the Irish), and we’re also world champions at dog shows, proper beer and indie guitar bands. But I’m not sure that these are things I would encourage my children to die patriotically in a trench for.

Winder offers a better answer, and it’s one that anyone brave or suicidal enough to pitch in to the contemporary European identity debate should consider. It offers a path through the horrible, thorny maze of arguments about race, ethnicity, migration and the like, towards something that, potentially, could unite people rather than divide them. What makes and forms a “people”, says Winder, in England as elsewhere, is the one thing they all share: the place itself. If there is an “Englishness” it is formed from the nature, literally, of England:

If we really wanted to search for the national identity, I thought, the real place to look was in the natural heritage of hills, valleys, rivers, stones and mists – the raw materials that had, over time, moulded the way we were. Landscape and history – the past and the elemental backdrop – were the only things we could truly claim as our own. Just as some plants thrive in sand and others in clay, so a national character is fed by nutrients it cannot alter.

Early on in the book, Winder quotes the novelist Lawrence Durrell, who makes the same case more provocatively:

I believe you could exterminate the French at a blow and resettle the land with Tartars, and within two generations discover… that the national characteristics were back at norm – the relentless metaphysical curiosity, the tenderness for good living and passionate individualism.

Durrell goes on to suggest that “a Cypriot who settled in London would in time become English, simply because human customs owe just as much to the local environment as to trees and flowers”. I’m in a position to test this hypothesis, because my grandmother was a Cypriot who settled in London. Did she become English? Well, she wore English clothes, lived in a bungalow, cooked roast dinners, won endless rosettes in endless dog shows and had her English friends call her Doris, because they had trouble pronouncing Demetra. On the other hand, she never lost her accent, her language or her connections to her homeland, and until the end of her life she made a mean baklava. I don’t know what any of that means, other than that labels can get confusing pretty quickly.

And that is Winder’s point: forget the labels, look at the land below your feet. That’s where your “identity” comes from. Take the last wolf in England, which gives the book its title. Allegedly killed in the 1290s by a Shropshire knight named Peter Corbet (the king had tasked this “mighty hunter” and other nobles with ridding the land of predators), the wolf’s end freed up the English to transform their landscape – in a way not available to many other European countries, whose wolf populations were too large and interlinked to kill off – into “the biggest sheep farm in the world”. This turned England, in the Middle Ages, into a wealthy wool economy. It was an agricultural revolution, shaping everything from land ownership to diet to class structures to the architecture of the Cotswolds, and it happened not just because the landscape was now wolfless, but because “the country was made for grass”.

The same soil and climate that made growing grass so easy did the same for wheat – which, mainly in the form of bread, has been the staple of the English diet from the rise of agriculture to the present day, when we eat more wheat than ever. Add in the later discovery of coal, which was found in rich seams across the country, and which gave rise to the Industrial Revolution and the British Empire, and Winder suggests, only slightly playfully, that the English national character can be summed up by way of an algebraic equation: e = cw4: “Englishness equals coal x wool, wheat and wet weather.”

The book’s central case – that “natural history might be a branch of political science” – is a necessary corrective to a public debate in which we are increasingly instructed to believe that virtually every aspect of our character is a “social construct”. Winder wants us to understand that much of it is actually a natural construct, which means in turn that our development is not entirely under our control. It’s not a message that many people want to hear in an age of selfies and consumer choice: “Just as each vineyard (or terroir) produces its own unique wine, so human beings are conditioned by their local landscape. We move around more now, so the lines are blurred, but the underlying skeleton of English culture – the bare bones of the national psyche – may have changed less than we think.”

I couldn’t help, as I read, wanting more detail on this “underlying skeleton”. Where are the folk songs, the rhymes and ballads? Where is the mythology? Where are the grainy details of the lives of the people who, throughout English history, were probably shaped by the landscape most of all, and who shaped it in turn – the peasantry? There are glimpses of all this, but there is also too much school-textbooky history of inventors and their inventions, of revolutions and wars. A book like this ought to start at the bottom – in the mud, in the mulch on the forest floor. I wanted an earthier, messier story.

Despite this, there is plenty to chew on here. The question that remained when it was over though, for this reviewer at least, was: is any of it true any more? It may once have been the case that human customs were formed by places, but is it now?

When people in England, or anywhere in the modern world, have more connection, via their handheld screens, with the mill race of global consumer “culture” than they do with the landscape around them, and when only a handful of us work on or really know that landscape, what chance does it have of forming the basis of our cultural life?

If English national character is so hard to pin down, could the reason simply be that there is no such thing any more; that the English, like other denizens of techno-post-modernity, are shaped not by their natural environment, but by the artificial one that is rising to enclose them like a silicon cocoon? When the heavy metals in your smartphone are mined in Indonesia, not Cornwall, what equation defines you – and do you even care? 

Paul Kingsnorth’s books include “Confessions of a Recovering Environmentalist ” (Faber & Faber)

The Last Wolf: the Hidden Springs of Englishness
Robert Winder
Little, Brown, 480pp, £20

This article first appeared in the 10 August 2017 issue of the New Statesman, France’s new Napoleon