Examining a Panacea

Scott Podolsky reviews Robert Bud’s Penicillin: Triumph and Tragedy.

By Scott Podolsky | November 25, 2008

Chemical structure of penicillin G.

Robert Bud. Penicillin: Triumph and Tragedy. New York: Oxford University Press, 2007. 340 pp. $65.00.

More than a story about a particular compound and its discovery and use, Robert Bud’s Penicillin: Triumph and Tragedy describes the story of penicillin as epitomizing the entire post–World War II structure of biomedicine, from the entwined realms of the pharmaceutical industry and government to the worlds of patients, doctors, and the society in which they are embedded. Bud has chosen the perfect representative, and he has performed his research and told his story remarkably well.

As Bud explains, during the pre–World War II era health promotion and disease prevention were understood to depend on individual and societal responsibility rather than on the emerging “wonder drugs” of the era. Yet also during this time scientists began to produce the “magic bullets” originally envisioned by Paul Ehrlich and seemingly exemplified by the advent of the sulfa drugs in the mid-1930s. Throughout this era the public and scientists continued to hope for still better wonder drugs. Hope alone, however, could not conjure a magic bullet with broader utility and less toxicity than the sulfa drugs. Rather, it would take biomedical collaboration on the scale of the Manhattan Project to produce such a drug—penicillin.

Bud skillfully chronicles the long history of penicillin’s emergence, from the mold in Alexander Fleming’s lab in the 1920s to the widespread production of the medicine by the end of World War II, to demonstrate the dependence of such an advance on an evolving collaborative science, in which biochemists and microbiologists, industry and academia, Britain and the United States, cooperated. And in penicillin’s case the scale of such cooperation would come to typify expectations of the scale of biomedicine more broadly in the postwar era.

Still more generally, penicillin emerged from World War II as a malleable and multifaceted “brand” (as Bud calls it) of biomedicine that could be used to tell stories of achievement and societal betterment. The new brand could be co-opted for nationalistic purposes, especially in Britain, where it served as a source of both pride over its discovery and anguish over its having been given away to the United States to develop on an industrial scale. Penicillin also came to represent the reaction against the austerity of the war and its aftermath, to typify the benefits and prospects of modernity itself. And as part of this reaction penicillin came to embody technological solutions for the health of society and its members, ready for their ever-increasing consumption and superseding the previous emphases on prevention and self-discipline.

Thus, when microbial resistance to penicillin and the antibiotics that succeeded it emerged and then spread by the 1950s, it was perhaps not surprising that the medical and scientific communities saw technological solutions (i.e., the generation of an arms race of antibiotics) as the natural means to confronting resistant pathogens. Throughout the ensuing decades physicians continued to prescribe massive amounts of antibiotics, well beyond those deemed necessary to contemporary specialists, which contributed to the increasing problem of resistance. Bud uses the powerful valence of antibiotic overprescription to reflect on the changing dynamics of the patient–doctor relationship itself. In this telling, an increasingly mistrusted, harried, and hurried medical profession wielded its new source of authority (the pharmaceuticals bequeathed by science) rather than relying on its traditionally revered role at the bedside to satisfy patient demands. Bud supports this analysis with a brief but telling review of the means by which antibiotics have been incorporated into, and have dynamically altered, discrete therapeutic and social systems around the world.

By the late 1960s, however, it was becoming obvious to many scientists that in the case of antibiotic resistance the entire world was ecologically linked, and measures would have to be taken to curtail resistance. Given the entrenched notion of the autonomous provider in Great Britain and the United States, the first object of the reformers’ collective gaze was not antibiotics prescribed for humans, but rather those used for animals. Much as antibiotics had helped alter conceptions and conditions of human health, they had fundamentally altered animal farming, serving as both an anti-infective in crowded conditions and a direct growth promoter. Debates among scientists, journalists, industry lobbyists, and government would ensue from the late 1960s through the 1980s concerning the implications for humans of such uses of antibiotics for animals, thus exposing clear political allegiances, especially over contested data.

By the 1980s and 1990s, when it had finally become apparent that such discussions could not take place without simultaneously discussing antibiotics prescribed to humans, antibiotic resistance had become a fully politicized topic. In the sobering era of HIV, bovine spongiform encephalopathy (mad cow disease), and an apparent host of “coming plagues,” such scientists as Joshua Lederberg and Stuart Levy brought increased attention to the resistance problem. This yielded a series of reports in both Europe and the United States, increased surveillance of resistant bugs, and, ultimately, increased focus on both antibiotic prescribing and hygienic practices. These new reports, combined with increased public attention, meant that physicians and their patients could once again work together, for their individual sake and for that of society, in promoting health and preventing unnecessary illness.

Penicillin, beyond the clear organization of its arguments, is full of fascinating archival references and anecdotes concerning events, scientists, and even individual cows from around the world. My only criticism concerns the title itself: Penicillin is in many ways as much about antibiotics broadly as about a single compound or even a brand alone. The different classes of antibiotics that followed penicillin have each had their own significance. For instance, the first "broad spectrum” antibiotics, the tetracyclines and chloramphenicol, helped usher in the modern era of pharmaceutical marketing, and even pharmaceutical branding itself, in the 1950s. A focused examination of this and other antibiotic developments and their repercussions could at times have lent more nuance to the story.

Bud is indeed skilled at drawing on the antibiotic story broadly when he needs to. This skill allows him to cast a critical light on the overall issues of implementing antibiotics and broader pharmaceuticals at a critical juncture in their history. Bud’s careful analysis makes his text important to policy makers, clinicians, and patients alike. As Bud reveals, in many ways the antibiotic era has come full circle. Yet, as he points out, it remains unclear exactly where it will end.