Hydrocortisone Relatedness

Drugs are exceptional objects; if not literally magical, they are certainly wonderful. Among the many technical and industrial artefacts that dominate our daily life, they benefit from a special status. This is hardly surprising considering that patients as well as medical practitioners see in them the power to relieve suffering and to cure, or at least to manage, disease. But drugs are also wonderful, exceptional objects for social scientists. They stand at the centre of complex networks that bind together the various professionals involved in their invention, the companies responsible for their production, the doctors who prescribe them, and the pharmacists who sell them, as well as the patients and consumers who take them. Drugs are therefore wonderful points of entry into the multiple worlds of our highly technological societies.

Gaudillière (2005, p.603)⁰

1. Introduction: ‘and don’t forget…’

Imagine. You’re in the congregation at the New Covenant Baptist Church in Chicago, in the USA. It’s the 9th of April, 1967. Clergyman and civil rights activist Reverend Dr. Martin Luther King Jr. is part way through his sermon ‘Three dimensions of a complete life’. He’s done this many times before, but he’s preaching passionately (and people are responding):

And don’t forget in doing something for others that you have what you have because of others. (Yes, sir) Don’t forget that. We are tied together in life and in the world. (Preach, preach) And you may think you got all you got by yourself. (Not all of it) But you know, before you got out here to church this morning, you were dependent on more than half of the world. (That’s right) You get up in the morning and go to the bathroom, and you reach over for a bar of soap, and that’s handed to you by a Frenchman. You reach over for a sponge, and that’s given to you by a Turk. You reach over for a towel, and that comes to your hand from the hands of a Pacific Islander. And then you go on to the kitchen to get your breakfast. You reach on over to get a little coffee, and that’s poured in your cup by a South American. (That’s right) Or maybe you decide that you want a little tea this morning, only to discover that that’s poured in your cup by a Chinese. (Yes) Or maybe you want a little cocoa, that’s poured in your cup by a West African. (Yes) Then you want a little bread and you reach over to get it, and that’s given to you by the hands of an English-speaking farmer, not to mention the baker. (That’s right) Before you get through eating breakfast in the morning, you’re dependent on more than half the world. (That’s right) That’s the way God structured it; that’s the way God structured this world. So let us be concerned about others because we are dependent on others. (Oh yeah).¹

Listen to this section of Dr King’s sermon on YouTube here.

Preaching this helped Dr King to get his first job as a pastor of the Dexter Avenue Baptist Church in Montgomery, Alabama in January 1954. It became one of the ‘tried-and-true’ sermons he gave on numerous occasions in the USA and overseas.²

I only found this sermon recently. But I’ve heard it all before. In the kind of academic work I’ve been reading. Have been influenced by. Inspired by. For years. Who must have been in the congregation that day. David Harvey? ‘Let us be concerned about others because we are dependent on others’?! Isn’t that why Harvey asks his students to think about where their breakfasts come from?³ Donna Haraway? ‘We are tied together in life and in the world’? Isn’t that Haraway’s manifesto for cyborgs? That ontological politics. In a nutshell? Him?⁴ Daniel Miller? ‘You reach over for a sponge, and that’s given to you by a Turk’? Isn’t that the kind of narrative approach to commodity de-fetishisation that Miller has been calling for, which makes each thing a ‘personalised objectification of the relationships that it creates’?⁵ He’s advocating ethnographic approaches to this. Autoethnography might work even better. Writing vulnerably so audiences might respond vulnerably. Maybe. Let’s see how it goes…

The problem with ‘follow the thing’ commodity de-fetishising research, as critics have pointed out lately,⁶ is that what’s studied is usually lavishly fetishised in advertising, product design and consumption. The commodities chosen are often the ones whose consumption is supposed to ‘take you there’. You know, like the tropical fruits and Jamaican food I’ve studied.⁷ I have to take on board these criticisms because these things are much more a part of my life / self /body as subjects to research and write about, than they are things to buy, eat, cook with, digest and so on. As Karen Bakker and Gavin Bridge have suggested, what’s being neglected in this broader literature are things that are more ubiquitous and important but perhaps less ‘obvious’ or ‘interesting’.⁸ Like stainless steel, they suggest. What are the imaginative geographies at work in their public fetishisation? Have you ever washed up in a Belgian sink? It really takes you there. And that Chinese lift door? Reminds me of that holiday I took… Ah.

This made me think about the stuff that I really need, but have no idea what it’s made from, what relations with whom / what / where it might embody, what new aspects of material / semiotic, hybrid / cyborg selfhood might be mobilised and/or recognised through finding out, and why/how this might be of relevance or interest to anyone but me. What about commodities that aren’t advertised to the public, that others decide that you should buy from whichever company that makes them, that aren’t available on any ‘open’ market, that others tell you exactly how, how much and when to consume? Like prescribed medicines. Stuff that might help you to cope with a chronic illness you’ve been diagnosed as having. Commodities that, in a way, choose you. Fit you. Ones that have to be added to your chemical and other selves on a daily basis, to help them to work better than they would otherwise. Hopefully. Stuff that ‘matters’, to you and to others near and far, in every sense of the term.

I first came across this idea when Ali Buckler, a student taking my Geographies of material culture module, submitted a journal entry on the thyroxine tablets she took [published on followthethings.com here]. Through Google-searching their specific ingredients, she’d found some amazing stories about the ‘unseen others’ who were helping thyroxine to help her to be herself every day, including Bedouin people, their camels and their camels’ chiropractors.

2. When a project chooses you

I’d thought that this was brilliantly original at the time. But it wasn’t anything I thought I’d ever try ourselves. Until October 2004… At home in Birmingham, in the UK. It’s mid morning. I’ve just started to notice a pain in my side. It’s quite faint to start with. But it gets worse and worse over the course of an hour or two. Until it’s excruciating. Serious. I can hardly move. Or talk. The pain is so intense I want to scream into a pillow. The noise sounds more like a braying donkey. Then the taxi comes. The driver takes me to the Accident and Emergency department of my local hospital. An hour or so later, an A&E doctor tells me it’s renal colic – the pain caused by a kidney stone making its way along the tube connecting kidney and bladder – and writes a prescription for a course of strong painkillers (dicolfenac and co-dydramol, along with zantac to dull the nausea they caused). The pain eventually subsides and I’m sent home.

Over the next few months, I return for two operations to remove the now-stuck stone, then stop taking the painkillers, and am relieved that this experience is over. Until, the following summer, my appetite goes and a considerable amount of weight is lost. I’m more grumpy and lethargic than usual. I’m constantly thirsty, and sleep at any time of day or night (even through a tornado).⁹ This change is alarming. Family and friends worry about what’s happening to me. They’re shocked at my appearance. I’ve become a ‘bag of bones’. Hollow cheeked. Gaunt. Emaciated. It’s painful to sit down. There doesn’t seem to be much muscle left between my skin and pelvis.

This is the summer I turn 40. Our children, both under 5, haven’t allowed us more than a few proper nights’ sleep since they were born. Work is really stressful. Under these circumstances, we speculate, maybe weight loss isn’t that unusual. But that pain comes back, again and agin. On both left and right hand sides. I try to sense when it’s coming, to catch it early, take the painkillers, drink copious amounts of water, and hope that will ‘flush them out’. Sometimes that works, but occasionally it doesn’t.

The pain doesn’t go away. It slowly gets more and more intense. The stone moves slowly. Scraping and scratching away at my insides. On several further occasions, I end up back in a taxi going to A&E for emergency help. I’m lucky, one driver says. Where he comes from there isn’t a National Health Service. People suffer that pain. In the waiting room, I check in and pace the floor, muffling the braying noises by biting my arm through my clothes. Apologising to other people waiting, often also in pain, to be seen. Telling the triage nurse, once I’m invited into the assessment room, what’s wrong and what treatment I need. Now! Being taken to a bay, asked to wait, curtain drawn, trying to get comfortable on the chair or bed, drinking more water, listening to other patients’ moans and screams. Making my own. I want a nurse to tell a doctor that I’m next, so I can get those painkillers.

One time, the pain subsided before the doctor came. The drugs I’d taken at home must have kicked in and/or the water had flushed the stone into my bladder. That’s what’s supposed to happen. Urology surgeons are reluctant to operate, unless there’s a serious blockage, the kind that can cause your kidney to fail. I’ve had a couple of those operations, too. The idea is that after the stones have been flushed into your bladder, there’s one more stage to their journey: ‘passed’ out, in your urine. But they’re not small. They’re rock hard and spiky. The ones in the photo below are some that I ‘passed’, with a kidney bean for scale. Getting them out can take a few days, and it’s eye-wateringly painful. I produced dozens. They kept coming. I started a collection to show the doctors how many.

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These symptoms are painful and ridiculous. Something strange is going on. So I make an appointment with my GP. She is curious. She sends me for a blood test, and ticks a few boxes on the form so that it will be tested for a range of different possible contents. I give the form to the phlebotomist. He takes a few samples from my arm, and attaches different stickers to the vials. Analysis confirms that I have ‘hypercalcaemia’. My blood contains an abnormally high level of calcium. That’s what’s getting filtered out by my kidneys to make the stones. Hypercalcaemia is not an illness, though. It’s a symptom. But of what? Where’s that calcium coming from? It’s not obvious.

My GP refers me to a consultant endocrinologist back at the hospital who is an expert on blood calcium. Let’s call him Nigel. A few weeks later, he tells me that hypercalcaemia can be caused by a number of conditions. I’ll have to have tests. Lots of them. Ultrasounds, x-rays, an MMR scan. I’m surprised that I find this whole process quite exciting. Like a whodunnit? Soon I’m back in his consulting room. He tells me that results of the tests suggest – but don’t confirm – an illness called ‘sarcoidosis’. Even though he advises me not to look it up online, I can’t help it. I find a US Department of Health and Human Services report that says it’s:

… a disease that causes inflammation of the body’s tissues. Inflammation is a basic response of the body to injury and usually causes reddened skin, warmth, swelling, and pain. Inflammation from sarcoidosis is different. In sarcoidosis, the inflammation produces small lumps (also called nodules or granulomas) in the tissues. Once thought rare, sarcoidosis is now known to be common and affects persons worldwide. In fact, sarcoidosis is the most common chronic fibrotic interstitial lung disorder.¹⁰

Sarcoidosis is most often found in people’s lungs. It has no obvious cause. It isn’t genetic. It is more common in African American communities. There is no cure. It usually just goes away in time, ‘with or without treatment’.¹¹ These granulomas can sometimes convert the body’s Vitamin D into an enzyme that removes more than the normal amount of calcium from food in the gut. It’s one of those diseases that you might never find that you’re ‘suffering’ from. Most people’s calcium leaves the body in urine in solution. Not as stones. I print out copies of the report for my partner Lucy, her mum, my mum. They’re reassuring. Not like the sarcoidosis blogs I found. They’re scary, upsetting, horrible. People die from this.

Meanwhile, Nigel refers me to his colleague Robert: a lung specialist. He’s seen the tell-tale shadows of sarcoidosis on my chest x-rays. But he can’t’t make a proper diagnosis without a lung biopsy that can grab a granuloma. The biopsy confirms their suspicions. Robert writes my first prescription for a steroid called hydrocortisone. In tablet form, this is going to help reduce the sarcoid inflammation and the excess conversion of Vitamin D, and hence get my blood calcium to ‘normal’ levels. The stones should stop forming and he and Nigel will monitor my condition to see what happens. This isn’t my body any more. I’ve let them in. I don’t mind.

3. we ❤️ hydrocortisone

I spend a lot of time in hospital waiting rooms. They’re great places to read & think. Especially when you want to do some new research that matters differently to you. On something that you know nothing about, have no idea where it might take you. So I start to think about my illness and treatment as a research project.

I take my hydrocortisone prescriptions to my local Lloyd’s pharmacy, pay the standard prescription fee and get four boxes (two of 10mg and two of 20mg tablets) of Hydrocortone®. Hydrocortisone (or synthetic cortisol) is the active ingredient. Hydrocortisone is an ingredient in 93 named drugs, manufactured by 37 different companies.¹² When I tell people what I’m studying, it’s amazing how it is, or has been, part of many of their bodies, or of those they know and/or care for:

If inflammation (swelling, heat, redness, and pain) is your problem, hydrocortisone can be injected into a large muscle (such as your buttock or hip), directly into your vein, or added to an intravenous fluid that will drip through a needle or catheter placed in your vein. Oral hydrocortisone, on the other hand, may be prescribed to treat certain forms of arthritis; skin, blood, kidney, eye, thyroid, and intestinal disorders; severe allergies; and asthma. Hydrocortisone is also used to treat certain types of cancers, such as leukemia, lymphoma, and multiple myeloma.¹³

Then there’s the topical hydrocortisone that is often part of the creams used to treat eczema. My daughters are also hydrocortisone consumers in this sense.

My tablets are made in a factory in Northumberland by a company called Merck, Sharpe & Dohme Ltd. The trademark is registered to Merck & Co. Inc, Whitehouse Station, NJ, USA. According to the information leaflet. They sit in their foil packaging, in their boxes, in a green Lloyd’s paper bag next to the radio in our kitchen. Waiting for me to remove and swallow 20mg in the morning and 10 in the afternoon, ‘with or after food’. At the moment. That’s much less than I started with.

I totally LOVE this stuff. This drug. This medicine. What’s in it. And these people, others, near and far who make and get it for me. It’s no exaggeration to say that, together, they have transformed my life. Brought back a ‘me’ that was disappearing. And exaggerated it, when the dose was too high. Then, whenever Lucy asked how my day had been, I always replied ‘amazing’, ‘brilliant’, ‘fantastic’. I was ridiculously enthusiastic. Robert said I was almost clinically ‘manic’. I couldn’t stop talking. I was buzzing with ideas and energy at home, at work and in those waiting rooms. In one consultation, I ask Nigel whether hydrocortisone is some kind of happy pill. I found references to it on the Web of Knowledge as an antidepressant prescribed to people at risk of suicide. These are the circumstances in which hydrocortisone seemed to choose me to study it.

I explain to Nigel what I do for a living, and mention that I am thinking of doing some ‘follow the thing’ research on hydrocortisone. I ask if I can have copies of my medical notes, and maybe – one day – interview him and Robert and others about them. He tells me about Peter, a local university Professor who is an expert on steroids, and has given a talk on the history of hydrocortisone prescription in the UK which begins with a local doctor illegally importing it from the US to treat his son who has been born without genitals and will die without the drug. The same condition was, he said, behind the papal seat – a device designed to anonymously check a new pontiff’s genitalia after the (mythical?) ‘Pope Joan’ incident. I’d have to follow that up.¹⁴ Nigel rocks back in his chair, really enjoying telling me these tales.

Nigel and Robert want to see me every couple of months. To check the results of blood tests, send me off for x-rays and lung function tests, and the like. To see how my sarcoidosis is doing. How I’m doing. Robert and I joke about whether Lucy might want the dose lowered to put me ‘back in my box’. But it gradually reduces my blood calcium to ‘normal levels’ by reducing the sarcoid inflammation in my lungs. So they gradually lower the dose to the minimum necessary to keep things at this level. We become stabilised. Me and my illness. I’m not so interesting now. My treatment is now a matter of monitoring, waiting, and lowering the dose – one day – to see whether the sarcoidosis has gone.

I calmed down. too. Except in my love of hydrocortisone, and everyone and everything that helps it come my way (including the UK healthcare system that allows me to call on its services by right). They / it sort me out. And that’s having a positive effect on Lucy, our kids, our wider family, friends, some colleagues, postgrads, more (possibly). Hydrocortisone helps things to be and/or to seem like this, anyway [Peter told me that hydrocortisone makes you feel happy but you’re taking it because you’re seriously ill]. To me, these hydrocortisone relations feel like a new part of my immediate and extended family. Caring for me, us. Sort of. ‘In person’. Face to face. But also passing something on – down the line – to contribute to my body, the way it looks, and the way it works. Who I / we were, are, can be. Then, now and in the future. This research becomes a genealogical project. I want to learn more about these ‘relations of care’ and ‘relatedness’ – social, biological, economic, otherwise – helping to make me, us.

4. hydrocortisone’s origin story

I try to explain this project idea to Peter, the professor of endocrinology who had given that talk. Nigel said I should meet him yo discuss my research idea. Before we do so, Peter suggests that I read the 1971 autobiography by Edward Kendall called Cortisone: memoirs of a hormone hunter.¹⁵ Kendall was a trailblazing American chemist who – with Philip Hench and Tadeus Reichstein – won the Nobel Prize in 1950 for their ‘discovery of hormones of the adrenal cortex their structure and biological effects’.¹⁶ Such was their fame at the time, that the announcement of William Faulkner’s Nobel Prize for literature was ‘almost a footnote in the world press’.¹⁷

In the first half of the Twentieth Century, ‘endocrinology was one of the most dynamic areas of biomedical research’.¹⁸ Endocrinologists, for example, had isolated epinephrine from the adrenal glands of sheep and cattle which was made commercially available by the pharmaceutical company Parke Davis as ‘Adrenaline’; isolated insulin from the pancreases of cattle which was made commercially available by Eli Lilly; and isolated thyroxin from hog thyroid glands which was made commercially available by Squibb.¹⁹ These and other successes ‘brought many other drug companies into closer collaboration with enterprising endocrinologists in an effort to repeat the story with the hormones of other organs’.²⁰

Kendall was a thyroxine endocrinologist, and had negotiated a deal with Squibb meaning that fifty percent of the profits from its thyroxine sales would be donated to the University of Minnesota which had just affiliated with the Mayo Clinic where he worked. This money funded his future research which, in the 1930s turned to ‘purifying and characterising the hormone of the adrenal cortex’.²¹ At this time, evidence was accumulating that patients with Addison’s Disease, ‘the deadly condition caused by acute adrenal insufficiency’ whose chief cause is tuberculosis, were not responding positively to treatment with the adrenal extract epinephrine. Mayo’s chief of medicine, Leonard Rowntree, was researching Addison’s disease, a visiting researcher had left behind meat presses he had used to isolate vitamin C from adrenal glands, Kendall had learned from his hydroxine work ‘the art of purifying scarce hormones from ground animal tissue’ and he set up a number of commercial deals with Chicago slaughterhouses and pharmaceutical companies to further finance his experiments.²² In 1935 he, along with rival Tadeus Reichstein in Switzerland, isolated adrenal gland hormones which were ‘capable of improving muscular strength when administered to … rats and dogs’ whose adrenal glands had been removed.²³

This story of scientific discovery was changed by war. After the ‘fall of France in May 1940 and the escalation of the air war over Britain … the [US] National Research Council (NRC) Committee on Aviation Medicine was formed to advise the United States military’.²⁴ Kendall described a secret conference at Yale University in May 1941 attended by ‘almost all of [those] who had made a contribution’ to studies of the ‘function of the adrenal cortex’.²⁵ There, they were told that severe cases of ‘flying stress’ in military pilots were being encountered ‘in which an Addison-like syndrome has appeared’.²⁶ There were unconfirmed rumours that ‘German scientists had beaten all others to the race to unravel the secret of the adrenal cortex. They were said to have made an extract that counteracted hypoxemia and permitted the pilots of the Luftwaffe to fly at 40,000 feet with impunity. Moreover, German submarines were on their way to Buenos Aires to obtain bovine adrenal glands for preparation of the extract.’²⁷ ‘This information made us feel like second-raters’, Kendall reflected, ‘If the chemists of the United States wanted to show what they thought they could do, now was the time to start’.²⁸ The Committee on Medical Research of the US Office of Scientific Research and Development subsequently made the development and mass production of cortical steroids one if its ‘top life science R&D targets for co-ordinated large scale research effort’.²⁹ At that time, 28 hormones had been separated from the adrenal glands of cattle and pigs, four of which ‘possessed physiological activity’ (called Compounds A, B, E and F). However, these were available in such limited supplies that experiments were only conducted on small animals.³⁰ To produce sufficient supplies of the envisaged ‘altitude-tolerance-booster’ using existing methods of extraction would have meant the slaughter of every single cow and pig in the United States.³¹

The race was on to develop a process through which these hormones could be partially synthesised from a starter material more ubiquitous than animals’ adrenal glands. The OSRD’s generous funding enabled Kendall to collaborate with scientists working for pharmaceutical company Merck and Co. In 1943 Tadeus Reichstein working with the Swiss pharmaceutical company CIBA and beat Kendall to the synthesis of Compound A, which had the simplest chemical structure. In 1944, Kendall announced a new synthetic pathway with ‘up to 1000 times the yield of Reichstein’s’.³² In 1945, trials of Compound A failed to ‘yield the desired effect’.³³ Attention was then diverted to the partial synthesis of Compound E which led to the 1946 publication by Kendall’s Merck collaborator Lewis Sarret of its ‘historic 37-step synthesis from desoxycholic acid’ derived from the bile of sheep and cattle.³⁴ This meant that Merck could produce a batch sufficiently large for Kendall and his rheumatologist colleagues Philip Hench to trial with human subjects at the Mayo Clinic in 1948.³⁵ The results of this investment came too late for their envisioned military use. That story of German Scientific advancement, Kendall wrote, ‘was built up out of whispers and rumours that were completely without foundation’.³⁶ Federal funding for this research stopped. But partially synthesised hormones could now be tested on human subjects. ‘The ‘triple-threat’ combination of a basic scientist (Kendall), industrial / pharmaceutical chemist (Sarett), and physician (Hench)’ had become set,³⁷ creating ‘a paradigm for translational endocrinology, the essence of which remains valid to this day’.³⁸

5. Cortisone miracles

Cortisone’s first human trials were with people suffering from rheumatoid arthritis which had been, until that point, ineffectively treated with ‘chin slings, gold injections, mineral baths, cobra venom, bee stings, even electricity’.³⁹ Edward Kendall suggested to Philip Hench, his rheumatologist colleague at the Mayo Clinic, that he should get in touch with Sarett to ask for the drug which ‘which had been earmarked for three clinical investigators to study its effect on Addison’s disease and diabetes, and for chemists for further chemical studies’.⁴⁰ Sarett sent him 9g.⁴¹

On September 21 a 29 year old women was admitted to the Mayo’s St Mary’s hospital with ‘debilitating joint mobility’ and was diagnosed with severe rheumatoid arthritis.⁴² Two days after being injected three times with small amounts of Compound E, ‘she woke with much less muscular stiffness and soreness, rolled over in bed easily for the first time in weeks and noted increasing strength and appetite’.⁴³ The next day she she was found exercising, ‘raising her hands over her head, [which was] previously impossible’ and ‘visited visited several patients to demonstrate her change in condition’.⁴⁴ ‘A week after her first treatment, she ‘left the hospital to enjoy a 3-hour shopping spree.’

There were similar stories of patients on the ward, ‘one … totally bedridden … was able to get out of bed and attempt to dance, another took seven baths in one day to compensate for the baths she had missed’.⁴⁵ These were results echoed the story in the New Testament describing ‘a paralysed man miraculously regaining the ability to stand and walk’.⁴⁶ When the clinic’s supplies of Compound E ran out, ‘all of the patients relapsed completely’.⁴⁷ Although this was sad for the patients, the scientists and doctors were elated. They ‘were on to an important breakthrough’.⁴⁸

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At a packed meeting at the Mayo clinic in April 1949, the results of the trial were announced. Twenty three patients had been treated. Films were shown of their capabilities before and after the treatment, and they had been interviewed about any ‘subjective changes’ they had experienced. ‘Only a phlegmatic person can watch that film without a lump in his [sic] throat or a mist over his eyes’, Kendall wrote. ‘For those who had known and worked with the patients it was a source of deep emotion. … the applause that broke out immediately after the conclusion … has never been equalled at any other meeting that I have attended.’⁴⁹ Despite efforts to make this a private event because ‘the full implications and complications’ of the study were not yet adequately understood, a medical correspondent from the New York Times ‘published sensational stories and pictures’⁵⁰ reporting ‘the first word on what may become one of the great landmarks of medicine, comparable to the discovery of insulin and of penicillin’.⁵¹

This press attention forced Hench’s hand at the Seventh International Congress of Rheumatology the following month where he showed the ‘motion picture’ film in his 12 minute slot.⁵² Rheumatologist Charles Plotz described what he saw: ‘They were severely crippled, having to drink by holding a cup in both hands. And Philip Hench gave them an injection, and within 12 to 24 hours, the same patients were having no difficulty at all. It was one of the most astonishing things that has ever happened in medicine’.⁵³ ‘A ‘wheelchair bound patient … got up to ‘dance a jog’ after ‘a few treatments’’.⁵⁴ The audience stood up and cheered’.⁵⁵ This landmark in the progress of medical research’⁵⁶ became well known as ‘cinemas worldwide showed newsreels of cripples rising miraculously from wheelchairs’.⁵⁷ This was when ‘rheumatoid arthritis began to serve as the prototype of a chronic illness, [and] corticosteroids provided pharmaceutical companies with a privileged angle of approach to the development of drugs against chronic diseases’.⁵⁸ And when ‘hormones took pride of place as life’s master molecules, and the endocrinologist took precedence over the geneticist as the scientist offering the means to control life’.⁵⁹

There were approximately 3 million people in the USA diagnosed with Rheumatoid arthritis⁶⁰ and every one ‘immediately wanted to be put on this magic drug’.⁶¹ A black market for cortisone immediately developed in the USA. ‘Patients who had experienced great relief of their symptoms were not prepared to relapse when supplies ran out. They became totally dependent on the drug. Overdosage led to devastating side effects, and the even escalating cost of maintaining their supplies resulted all too often in financial destitution. Such patients has no alternative but to seek relief by registering as guinea pigs to research groups’.⁶² This was a wonder drug, a miracle cure, but reports in medical journals and the lay press made these claims in a premature and overenthusiastic way. When the treatment was withdrawn, ‘patients experienced a relapse in the symptoms, often accompanied by depression’.⁶³ Compound E was extremely rare and expensive. Only the richest few could afford what was needed to treat this chronic illness.

Up to this point, the compounds given to patients had been extracted from animals, which was extremely inefficient. One method used in 1944 required the bile of 2,500 cows to make just 15mg of cortisone.⁶⁴ That’s my evening dose. So, pharmaceutical companies and their scientists worked to replace extraction with synthesis, which often started with existing plant substances that were also steroids – e.g. in yams or soy beans⁶⁵ – through a series of chemical reactions, these could produce human steroids. Here, for example, trying to find out who was doing this where, I discovered the story a Mexican company called Syntex, which Gary Gereffi – the pioneer of Global Commodity Chains research – studied for his PhD.⁶⁶ Drugs become cheaper if there are fewer steps in these chemical transformations. And costs are set to fall further with the latest breakthrough in steroid manufacture: bio-synthesis. Here, Merck’s European rival Sanofi-Aventis has developed a way in which genetically modified baker’s yeast, fermented with sugar or alcohol, can produce pure hydrocortisone in a single stage.⁶⁷ Biosynthesis is much faster, more yield efficient, purer, less polluting, and much less labour intensive, and should allow Sanofi-Aventis to compete with the low cost production of its Chinese competitors. If all goes to plan, bio-hydrocortisone products should be on the market this year.

But where do the ingredients of this hydrocortisone come from – the yeast, the sugar, the alcohol and – most interestingly – those genetic modifications? Denis Pompom has argued that it was ‘necessary to entirely reconstitute in yeast the human chain of biosynthesis of hydrocortisone, ‘to humanize it’.’ And the genes that cross species to make this happen, he says, come from ‘microbes, fungi, plant, fish, animal, even man.’⁶⁸ These cells can reproduce themselves, new genes included. I think. So, there’s more to ‘humanizing’ this commodity than finding out what happens in that factory in Northumberland.

6. A forgotten genius

It might seem strange to have started this paper with King’s sermon. And in 1960s civil rights activism. But before I met Peter, I’d Googled ‘hydrocortisone’, ‘synthesis’ and ‘history’ and came across a chemist called Percy Lavon Julian. The first hit was a critical review in the Journal of blacks in higher education, of the 1996 Cambridge dictionary of scientists. Of its 1,300 biographical entries, it said, none were African American. Eleven, at least, were listed as missing: the first of which was Julian. He had, it said, been ‘instrumental in the development of cortisone and other drugs to treat arthritis’.⁶⁹

Julian’s school education had been so poor before he got to De Pauw that he had to take remedial classes for two years. He worked as a waiter in a white fraternity house and slept in its attic. He gradated in 1920 as ‘top man of his class’ and was expected to be offered a plum PhD place because of this. His professor told him he’d been encouraged by other chemistry professors to ‘Discourage your bright coloured lad. We couldn’t get him a job when he’s done, and it’ll only mean frustration. In industry, research demands co-work, and white boys would so sabotage his work that any industrial research leader would go crazy!’⁷⁰ He should go for a job where he didn’t need a PhD, teaching in a Southern US ‘Negro College’.⁷¹

He did this for a while before receiving a fellowship to study for his PhD in Vienna – where he saw German chemists preparing sex hormones from Soya beans – and then returned to the USA. Back home, he struggled to develop his academic career – despite the brilliance of his work – because the trustees and regents of the university departments that wanted to employ him refused to appoint a Black professor.⁷² So he left academia to join the private sector as director of research for The Glidden Company of Chicago’s Soya Products and Vegetable and Oil divisions. This, was the turning point of Julian’s career. He was successful, made Glidden a lot of money, and then left in 1954 to set up his own Julian Laboratories Inc. in Chicago and Laboratorios Julian de Mexico S.A. in Mexico City.⁷³ Julian became famous as a soybean chemist who had, among other things, synthesised cortisone from soybeans which meant that its cost ‘dropped from several hundred dollars to only pennies per treatment’.⁷⁴

Peter had never heard of him. Perhaps that’s not surprising. A month before Philip Hench addressed the Nobel audience in 1950, Julian’s house in Oak Park – the fashionable suburb of Chicago where Ernest Hemingway, Frank Lloyd Wright and Ray Kroc also lived – was the subject of an arson attack and, the following year, a dynamite bomb was tossed at his house from a speeding car.⁷⁵ Julian was the first African American to buy a house in the neighborhood.⁷⁶ An editorial in the Chicago Sun reporting on the arson attempt said:

We wonder whether these cowards whose mad prejudice drove them to commit a felony would refuse to use the lifesaving discoveries of Dr. Julian because they came from the hand and brain of a Negro. Would they refuse to take synthetic cortisone if they were wracked with the pain of arthritis? Would they forbid their wives the use of synthetic female hormone now abundantly available because of Dr. Julian’s work? Would they refuse to use his synthetic physostigmine if they were afflicted with the dread eye disease, glaucoma? If they themselves were caught in a raging gasoline fire such as they tried to set, would they order the firemen not to use Dr. Julian’s great discovery, chemical foam. This stuff saved the lives of thousands of American airmen and sailors after crash landings during the war. No! The bigots welcome the discoveries of Dr Julian the scientist, but they try to exclude Dr. Julian the human being.⁷⁶

Hydrocortisone is still being manufactured the Julian – soybean – way, as it is ‘one of the most inexpensive ways of making this important chemical today’.⁷⁷ This, and over 100 other chemical patents, made Julian extremely wealthy. In 1961, he sold one of his companies – Julian Laboratories Inc. – to Smith Kline French for $2.3m. A 1946 Reader’s Digest article explained how far he’d come. Leaving Montgomery Alabama to go to De Pauw University in 1911, it states:

…he had looked out of the window of a Jim Crow coach at his family, all standing waving. His little grandmother, who had once picked a record 350 pounds of cotton in a day, had waved a hand wrinkled with her 99 years. His grandfather had waved a hand from which two fingers were missing, cut off long ago because his master had found he’d learned to write.⁷⁸

Alongside his life as a successful and prolific chemist, Julian fought for civil rights for over 50 years, founding ‘the National Negro Business and Professional Committee for the Legal Defense Fund and raised money for the NAACP and was a contributor to Dr, Martin Luther King Jr. and the Southern Christian Leadership Conference’.⁷⁹ In the 1960s, he was considered to be an elder statesman of the civil rights movement, having spent ‘countless nights preparing and giving speeches, stirring his fellow citizens to deeper thoughts about human rights problems and the way to a better America.⁸⁰ In 1967, for example, he wrote:

The false concept of basic Negro inferiority is one of the curses that still lingers. It is a problem created by the white man. Our children just no longer are going to accept the patience we were taught by our generation. We were taught a pretty little lie – excel and the whole world lies open before you. I obeyed the injunction and found it to be wishful thinking.⁸¹

For him, the challenge for the ‘Negro scientist’ living in the ‘American ghetto and the American brand of apartheid’ was for their ‘total intellectual integrity’ to ‘tak[e] mastery of the frustrating necessity to bolster his waning spirits’.⁸² Julian saw this ‘new breed as an unusual humanist-scientist combination’,⁸³ whose societal contributions could – Edward Jenkins argues – ‘benefit.. mankind [sic.], without regard to race or station in life’.⁸⁴ At Julian’s funeral in 1975, one of his closest friends described him as ‘A man who made contributions to healing, not only of the body, but of our society where he has built bridges between many groups.’⁸⁵

7. Citizenship, kinship, thingship?

So, this isn’t a follow the thing study where the task is to find connections between the people who work in pharmaceutical factories (and in the places where their ingredients are sourced) and the people to take those medications. This is a different, more historical form of following. That’s what was possible and fascinating with the sources we found online. So we went for it, followed lines of enquiry that were presented to us. And it’s made us think differently about the connections that ‘follow the things’ work can help to make.

These hydrocortisone relations – as mentioned earlier – have felt like a new part of my immediate and extended family. Caring for me, us. Sort of. ‘In person’. Face to face. But also passing something on – down the line – to contribute to my body, the way it looks, and the way it works. Who I / we were, are, can be. Then, now and in the future. This is one of the reasons why we write as Ian Cook et al – because nobody works, or can exist, alone.⁸⁶ An autoethnographic following of medicines can show, as Andrew Collier says, how ‘our material being is more extensive than the space enclosed in our skins.’⁸⁷

We’re used to studies of ‘citizenship’ and ‘kinship’ thinking through individuals’ relations to wider collectives, and the rights and responsibilities that go along with this. A lot of commodity and trade justice researchers would, we imagine, give their right arms to find new ways of extending that sense of collective identity, those concerns about rights and responsibilities, to those places, people, others whose lives are connected through the traffic in things. We have been inspired to think this way by kinship geographer Catherine Nash who, drawing on the writing of Donna Haraway, has asked:

what are the effects of considering kinship vis-a-vis understandings of relationality that extend the meaning of the social to include objects, entities, institutions and technologies of all kinds in complex networks and in continual processes of co-emergence? One response to this question would be to explore … the ways naturalised idioms of kinship are mobilised outside their familiar domain. Themes of ancestry and descent, for example, central to the lexicon of kinship, cut across themes of connection and difference between people and other animals and between other things.⁸⁸

This hydrocortisone-following, this cyborg ontology, these narratives of connected lives, surely comprise some kind of -ship, too. So, how about ‘thingship’: the qualities, states, conditions, collective bodies united, related, via things? ‘Things in the capitalist mode of production’, Timothy Luke argues, ‘possess spirits of someone other than those who use them, and, in turn, these things transfer those properties, share their energies, disclose an older intelligence to new users, possessing them with their spell.’⁸⁹

This makes sense to us, as an academic and as a consumer of prescription drugs. Bringing these ideas and experiences together, is our attempt to develop a sense of hydrocortisone relatedness. When we’re thinking about hydrocortisone relatedness, it goes something like this:

Ian! Don’t forget in doing something for others that you have what you have because of others. Don’t forget that. We are tied together in life and in the world. You may think that you got all you got by yourself. But, you know, you get up in the morning and go to the kitchen, and you reach over for that green Lloyd’s paper bag, and that’s handed to you by a Birmingham pharmacy worker. You reach into that bag for those drugs, and they’re given to you by a factory worker in Northumberland. You put them into your mouth, wash them down with some water, and their active ingredient is given to you by cows, soya beans or GM yeast and alcohol. You catch your reflection in the kettle, and are reminded that your good health was returned to you by those Birmingham doctors, those American chemists, that international drug company, everyone and everything else. Before you get through the first half hour of your waking day, you’re dependent on more than half the world. So be concerned about others because you are dependent on others.