Negotiating hospital infections: the debate between ecological balance and eradication strategies in British hospitals, 1947-1969

What and how can we learn from complex global problems for antimicrobial resistance policy? A comparative study combining historical and foresight approaches

OBJECTIVES

To (i) develop a methodology for using historical and comparative perspectives to inform policy and (ii) provide evidence for antimicrobial-resistance (AMR) policymaking by drawing on lessons from climate change and tobacco control.

METHODS

Using a qualitative design, we systematically examined two other complex, large-scale policy issues-climate change and tobacco control-to identify what relevance to AMR can be learned from how these issues have evolved over time. During 2018-2020, we employed a five-stage approach to conducting an exploratory study involving a review of secondary historical analysis, identification of drivers of change, prioritisation of the identified drivers, scenario generation and elicitation of possible policy responses. We sought to disrupt more 'traditional' policy and research spaces to create an alternative where, stimulated by historical analysis, academics (including historians) and policymakers could come together to challenge norms and practices and think creatively about AMR policy design.

RESULTS

An iterative process of analysis and engagement resulted in lessons for AMR policy concerning persistent evidence gaps and uncertainty, the need for cross-sector involvement and a collective effort through global governance, the demand for new interventions through more investment in research and innovation, and recognising the dynamic relationship between social change and policy to change people's attitudes and behaviours are crucial towards tackling AMR.

CONCLUSION

We draw on new methodological lessons around the pragmatism of future- and policy-oriented approaches incorporating robust historical and comparative analysis. The study demonstrates proof of concept and offers a reproducible method to advance further methodology, including transferrable policies that could tackle health problems, such as AMR.

Antimicrobial Resistance and the Evolution of International Health Politics (1945-2022)

Despite being acknowledged as a major global health challenge, growing levels of antimicrobial resistance (AMR) in pathogenic and commensal organisms have proven an awkward fit for international health frameworks. This article surveys the history of attempts to coordinate international responses to AMR alongside the origins and evolution of the current international health regulations (IHR). It argues that AMR, which encompasses a vast range of microbial properties and ecological reservoirs, is an awkward fit for the 'organismal' philosophies that centre on the rapid control of individual pathogens that have characterised international policy-making since the 19th century.

From lighthouse to hothouse: hospital hygiene, antibiotics and the evolution of infectious disease, 1950-1990

Upon entering clinical medicine in the 1940s, antibiotic therapy seemed to complete a transformation of hospitals that originated in the late nineteenth century. Former death sinks had become harbingers of therapeutic progress. Yet this triumph was short-lived. The arrival of pathologies caused by resistant bacteria, and of nosocomial infections whose spread was helped by antibiotic therapies, seemed to be intimately related to modern anti-infective therapy. The place where such problems culminated were hospitals, which increasingly appeared as dangerous environments where attempts to combat infectious diseases had instead created hothouses of disease evolution. This paper will focus on one aspect of that history. It caused clinical medicine and hospital hygiene in particular to pay attention to a dimension of infectious disease it had previously paid little attention to thus far: The evolution of infectious disease-previously a matter of mostly theoretical interest-came to be useful in explaining many phenomena observed. This did not turn hospital hygienists into geneticists, though it did give them an awareness that the evolution of infectious disease in a broad sense was something that did matter to them. The paper advances its argument by looking at three phases: The growing awareness of the hospital as a dangerous environment in the 1950s, comprehensive attempts at improving antibiotic therapy and hospital hygiene that followed from the 1960s and lastly the framing of such challenges as risk factors from the 1970s. In conclusion, I will argue that hospital hygiene, being inspired in particular by epidemiology and risk factor analysis, discussed its own specific version of disease emergence and therefore contributed to the 1980s debates around such topics. Being loosely connected to more specialized studies, it consisted of a re-interpretation of infectious disease centred around the temporality of such phenomena as they were encountered in day-to-day dealings of clinical wards.

Penicillin: promise, problems and practice in wartime Edinburgh

While medical historians have paid ample attention to the introduction of antibiotics and their impact on hospital-based practice during and after the Second World War, the multiple issues surrounding their use in Scottish hospitalsare sorely lacking in current discussions. Drawing on an extensive yet underused range of materials including patient treatment records, oral histories and medical correspondence, this paper explores the introduction of penicillin for civilian treatment at the Royal Infirmary of Edinburgh during the closing stages of the War. It highlights the success of the drug in clinical treatment as well as its shortcomings, offering an alternative view of its initial impact on surgical practice.

Re-Inventing Infectious Disease: Antibiotic Resistance and Drug Development at the Bayer Company 1945-80

This paper analyses how research on antibiotic resistance has been a driving force in the development of new antibiotics. Drug resistance, while being a problem for physicians and patients, offers attractive perspectives for those who research and develop new medicines. It imposes limits on the usability of older medicines and simultaneously modifies pathologies in a way that opens markets for new treatments. Studying resistance can thus be an important part of developing and marketing antibiotics. The chosen example is that of the German pharmaceutical company Bayer. Before World War Two, Bayer had pioneered the development of anti-infective chemotherapy, sulpha drugs in particular, but had missed the boat when it came to fungal antibiotics. Exacerbated by the effects of war, Bayer's world market presence, which had been considerable prior to the war, had plummeted. In this critical situation, the company opted for a development strategy that tried to capitalise on the problems created by the use of first-generation antibiotics. Part and parcel of this strategy was monitoring what can be called the structural change of infectious disease. In practice, this meant to focus on pathologies resulting from resistance and hospital infections. In addition, Bayer also focused on lifestyle pathologies such as athlete's foot. This paper will follow drug development and marketing at Bayer from 1945 to about 1980. In this period, Bayer managed to regain some of its previous standing in markets but could not escape from the overall crisis of anti-infective drug development from the 1970s on.