Germs and Governance: the past, present and future of hospital infection, prevention and control
Home > Germs and Governance: the past, present and future of hospital infection, prevention and control
by Marguerite Dupree (University of Glasgow)
This blog is based on the author’s co-edited volume (with Anne Marie Rafferty and Fay Bound Alberti) published by Manchester University Press in March 2021.
Contributors: Flurin Contrau, Sally Sheard, Pamela Wood, Claire L. Jones, Susan Macqueen, Thomas Schlich, Jennie Wilson, Rosemary Cresswell, Susan Gardiner, Neil Wigglesworth, Alistair Leanord, Anne Marie Rafferty, Fay Bound Alberti and Marguerite Dupree.
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Long before the global Covid-19 pandemic began in January 2020, infection control was one of the twenty-first century’s most challenging health problems, with national and international stress on the growing dangers of anti-microbial resistance (AMR). This volume, one of the outcomes of a Leverhulme Trust research project grant, brings together historians, healthcare professionals and policymakers, and emphasises, not only drug therapies, but the whole range of infection prevention and control policies and procedures used to minimize the risk of spreading infections in hospitals and healthcare facilities. An historical perspective reveals the continuing importance of a broad spectrum of infection prevention and control practices, technologies and personnel—from hand washing to personal protective equipment to all levels of hospital staff—which the recent pandemic has spotlighted and reinforced. With cures limited, the need to devote adequate resources to all aspects of infection prevention and control emerges clearly, alongside the search for new classes of antibiotics and vaccines.
Germs and Governance captures a crucial transition in understanding infection prevention and control policies in health history since the mid-nineteenth century, including first, the growing recognition of the role of microbes in creating infection and disease, and second, an emphasis on managing microbes, in which the governance arrangements of the hospital and healthcare providers play a prominent, yet little-studied, role in mediating policy and practice. The volume offers the integration of historical and contemporary evidence, and a plurality of voices and experiences, which give the book a greater range and scope than does the existing literature. In eleven articles framed by an introduction and conclusion, the authors look beyond the antimicrobial drug revolution to focus on the other technologies and personnel of hospital infection control. Working in the context of a 150-year chronology, the contributors start with the general hygiene and specific antiseptic policies of Florence Nightingale and Joseph Lister, leading to a period of consolidation in the early twentieth century, the advent of sulpha drugs and antibiotics in the middle of the twentieth century and the increasing recognition of antibiotic resistance from the late 1950s onward, and the subsequent professionalization of infection control teams together with increasing attention to patient safety more generally.
Several important themes emerge. First, significant continuities have characterised infection control, despite associated transformations in medicine and the changing burden of particular pathogens. The tension between standardisation (in, for example, aseptic techniques or surgical checklists) and local control has persisted, with advantages and disadvantages to both. Also, ‘success’ has been the function of the investment of time, money and attention to infection control as a hospital priority, often stimulated by newly recognised pathogens and/or approaches. Yet, as Leonard points out in the volume’s penultimate chapter, even in today’s evidence-based medicine, gauging the efficacy of particular measures remains difficult in the setting of multiple and simultaneously moving parts.
Second, humility and self-reflection in the face of difficult assessments are useful in the long run. Historians and others can play an important role in puncturing smug, linear histories of the advancement of infection control measures by reminding us of the diversity of seemingly rational approaches proposed at any given moment. Schlich provides an exemplary demonstration in his account of the advent of surgical gloves amidst a variety of alternative approaches to avoiding wound infections in the late-nineteenth century. Similarly, both Wood and Wilson point to the degrees to which intuitive notions of ‘dirt’ and self-preservation—rather than evidence per se—have often driven both policies and compliance.
Third, the volume’s contributors challenge us to think across boundaries. Condrau highlights the emerging recognition, alongside the advent of antibiotic-resistant staphylococci in the 1950s, of the ‘two-way traffic’ between hospital and community, urging us to see the hospital as both socially and microbiologically embedded in its surrounding community. Wood, Jones, Creswell, and Gardiner look at the evolving boundaries and relationships among physicians, nurses and bacteriologists in taking responsibility for healthcare-associated infections. While gendered hierarchies between physicians and nurses have long histories—so do cultures of blame.
Fourth, Sheard points to a further set of actors—hospital administrators and economists—and the history of concerns over relationships between length of stay in hospital and hospital-acquired infections. She points to the increasing application of economic analysis to hospital-acquired infections, both locally and systemically, reminding historians to look across disciplinary boundaries and engage with broader scholarship and policy formation.
Finally, Macqueen, Wigglesworth, and Leonard emphasise the importance of ‘political will’, guidelines and effective financial investment in bringing about the decline in hospital acquired infection in Britain in the early twenty-first century.
The geographic focus here is on England and Scotland, but the contributors writing before the Covid-19 pandemic, make wider comparative references to other countries, including the United States, Europe, Canada, Australia, and New Zealand, recognising that infection prevention and control is a global issue.
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