It often seems, to doctors at least, as if trust in medicine is inversely proportional to its ability to save lives. When doctors could do little more than hold their patients’ hands as they died, often hastening their deaths with their absurd prescriptions, they enjoyed absolute trust. As soon as they could actually save lives, however, mistrust set in and writs began to fly. It is really most aggravating (for doctors).
An editorial in a recent edition of the New England Journal of Medicine draws attention to the current widespread mistrust of antibiotics. The authors are right to do so: I have quite often heard it urged against the benefits of modern medicine that it has produced bacterial resistance to antibiotics, as if this would be of any consequence if there were no antibiotics in the first place. No one would refuse an anaesthetic for an abdominal operation because there had been thousands of anaesthetic accidents since ether was first introduced.
That antibiotics had side-effects was recognized early in their career: and where side-effects come, can lawsuits be far behind? The first thoughts of those whose lives have been saved by them, albeit at the cost of damage either temporary or permanent, turn to compensation.
In my pharmacology textbook as a student there was a “natural history” of attitudes to a new drug. First it was a miracle-worker; then it was deadly poison; finally, it was useful in some cases. Attitudes to antibiotics seem to be following this pattern.
Only those who can relive, either in their memory or imagination (which is much rarer), what it was like to be ill in the pre-antibiotic era can appreciate the rapture with which the development of antibiotics was greeted. The authors of the NEJM editorial exaggerate slightly when they write that, before antibiotics, pneumonia ended in death; only a significant percentage of cases did so. But all the same, antibiotics represented one of the greatest advances in the history of medicine. They initially raised hopes of a permanent victory over infectious diseases.
The editorial mentions two men very important in the history of the discovery of antibiotics, Paul Ehrlich and Alexander Fleming. The first discovered salvarsan, the arsenical drug against syphilis; the second penicillin. Interestingly, the editorial omits a third, equally important name, that of Paul Domagk. It was he who, in 1932, discovered prontosil, the first sulphonamide and the first drug of use in bacterial pneumonia and staphylococcal wound infections. He was awarded the Nobel Prize for his discovery in 1939, but he did not rest on his laurels. He later did some of the research that led to the discovery of isoniazid, one of the first antitubercular drugs. So why is the name of this pupil of Ehrleich’s omitted from the editorial?
He discovered prontosil while working at IG Farben, of subsequent infamy. An aura of Nazism surrounds him: the blurb of a history of the discovery, “The Nazis discovered it. The Allies won the war with it.” The Nazis did not discover it, though it is true that they conducted notorious experiments in the camps with it.
Besides, Domagk was not a Nazi. Indeed, he was arrested and imprisoned briefly by the Gestapo. The Nazis prevented him from collecting his Nobel Prize, and when he did so in 1947 it was too late for him, under the rules, to receive the money. But perhaps the fact that he did not flee Germany during the Nazi era makes him suspect: so best to play safe and not mention him.
The authors of the editorial come to the implicit conclusion that you should take antibiotics when they are needed, but not otherwise: true of all medicines, in fact. The art is in knowing when it is necessary.
Image and thumbnail courtesy shutterstock / Michal Kowalski
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