Therapeutics of my Alternate History

I’ve touched on this topic before on here, but I find my mind often wandering to what the development of drugs, especially medicinal drugs, might look like in a science-fictional alternate-history timeline like mine that diverges around 1900 and has had a century for all those little changes to add up, leading to potentially a very different pharmaceutical landscape. When you get down to it what sort of therapies we use, what sort of drugs take off for recreation, is historically contingent, being as much based on the whims of fashion as the findings of science. For example, there’s no discernible scientific reason why Adderall is our go-to treatment for ADHD instead of Desoxyn.

What drugs we use are shaped by social attitudes and ideology as well, to a much more profound extent. Sotto voce our attitude seems to be that if addicts like to take a drug or if it gives a few old people heart attacks then the proper course of action is to not allow anyone to have it. Which is a huge problem for the rest of us, since basically any drug that actually works tends to be well-liked by abusers (triggering the puritan cult) and/or have substantial side effects (triggering the safety cult). In my alternate history attitudes in the 20th century evolve rather differently; maximizing effectiveness is prized over minimizing risk, and there’s little to no stigma against taking even the hardest drugs for therapeutic or performance-enhancement purposes.

Shock Treatments?

For instance, I suspect Accutane, which cures acne yet has some rather rough side effects while on a treatment course, will be the go-to treatment in my universe for all but the mildest cases of acne in teenagers. This is likely also a world where electroshock therapy remains the first-line treatment for clinical depression, among a few other mental disorders, by now joined for other disorders by transcranial magnetic stimulation and (possibly; the jury’s still out on this one in real life) ketamine infusions. Psychedelic therapy also looks very promising (MDMA for PTSD is the standout so far, but anecdotally that’s just the tip of the iceberg).

All these amount to shock treatments, heroic interventions that knock the body around and force a reset, rather than the safety-first approach prized by real-life research and medical practice. Already this looks rather different, but this fundamental difference in paradigm reshapes whole other fields of medicine as well.

Steroids FTW!

Take the NSAIDs, for example. The whole brand name, which stands for “non-steroidal anti-inflammatory drugs” was created in the 1950s, and became prevalent over the more effective steroid medications (speaking generally, of course; NSAIDs have interesting and useful properties), because of the negative association people had even back then between corticosteroid medication and anabolic steroids used for performance enhancement purposes.

Well, in my universe steroids, both anabolic steroids and corticosteroids (not to mention the neurosteroids, some of which are anaesthetics (is there anything steroids can’t do…?)), are in widespread and accepted use for performance-enhancement purposes, and in any case drug abuse concerns don’t affect medical practice much, so rather than ibuprofen and naproxen the first-line over-the-counter treatments for reliving aches, pains, inflammation, and infection are prednisone and dexamethasone.

The corticosteroids in particular have been demonized over the years, but the truth is at the low doses typically used in medicine they have rather minimal side effects, and are very effective at treating a mind-mindbogglingly wide variety of conditions. Turns out anti-inflammatory drugs that suppress the immune system and also happen to be hormones are very useful. In my alternate timeline I anticipate the corticosteroids will be much more widely-used than today, making them contenders for the top of the list.

Putting the Coca back into Coca-Cola?

Corticosteroids can be used as pep pills, since they do give you energy, and can be effective performance-enhancers especially considering their anti-inflammatory properties, but the go-to pep pills for both medical and performance-enhancing use in my universe will likely remain the classic stimulants: amphetamine and cocaine (or even, as with the Nazi “D-IX” formula, a blend of both).

Without the stigma and criminalization around it, I could easily envision coca tea displacing caffeinated tea to a large extent, and the coca being put back into Coca-Cola; at least for some people cocaine gives less jitters per unit of energy than caffeine does. Amphetamines too could steal a lot of caffeine’s thunder. But barring the coca tea or coca-cola equivalent of Death Wish Coffee this would amount to a different brew of more or less the same beverages rather than any really substantial change.

Diet Pills that actually work: yes, really!

That would come from the more hardcore pep pill version of amphetamine, which is one of the vanishingly few drugs that are actually effective for weight loss. If environmental conditions conspire to craft an obesity epidemic in my world its effects likely won’t even be noticeable; the default response in my universe will be to take more pep pills to keep the weight off rather than surrender to becoming fat, tired, ugly blobs as if it’s an inevitability. A few people getting heart attacks won’t stop them. Amphetamine also does a great job at covering up the mass lethargy and fatigue that’s so prevalent in modern environments, and is the most effective known nootropic to boot.

Diet Pills that actually work too well for their own good?

The final boss of weight loss drugs is also fully embraced in my world. I’m talking, of course, about 2,4-Dinitrophenol, better known as DNP, a mitochondrial uncoupler that burns fat, and fat only, at astonishing rates. You’ve probably never heard of it, and there’s a good reason for that: it has severe side effects. The fat is burned off in the form of heat, meaning the dosage must be precisely controlled so you don’t get hyperthermia and cook to death from the inside out, and it also can cause peripheral neuropathy, skin lesions, and cataracts, in addition to turning your white bodily fluids, including the whites of your eyes (!), yellow (it’s a potent yellow pigment). Oh, and in powder form it’s also a high explosive. DNP has been described as the only substance to be banned by both the FDA and the Department of Homeland Security for unrelated reasons.

In my universe DNP achieves mass adoption and becomes a staple of medicine regardless, due to its unmatched effectiveness; at moderate doses well below the maximally-effective nearly-lethal range it still helps to keep the fat off but has much less in the way of toxic side effects. Notably, it engenders lethargy, not climbing the walls (of obvious utility for those who don’t respond well to pep pills). The mechanism of action, uncoupling the mitochondria so they make heat instead of fat, is completely different from the stimulants, and interesting enough that uncoupling proteins found naturally in the human body have been the subject of research as anti-obesity treatments in recent years.

Wonder Drug in waiting?

DNP has other interesting properties; its thermogenic effect is a liability in temperate climates, but in truly frigid weather it becomes an asset. The Red Army took it to keep warm in WWII, and in more recent times people have even worked in meat lockers all day in complete comfort with no need for winter clothing thanks to DNP. In principle, the colder the environment the higher the dose, i.e. the faster fat could be burnt off, that could be tolerated, which in my timeline leads to the creation of cryogenic medical spas like in “The Coldest Inferno”.

Interestingly enough, there’s even evidence DNP at low doses (as in 1/20-1/200 as much as the usual high-dose weight loss regimen) has a variety of neuroprotective and anti-aging properties. Which might seem a bit odd, since at high doses it’s known to be neurotoxic, but if true it would be far from the first substance shown to have a hormetic dose response. If this information turns out to be true it’s possible in my timeline supplements like multivitamins might contain such low doses of DNP, making it perhaps the most widely used drug in my universe that’s currently illegal.

Radiation Hormesis FTW?

Speaking of hormesis, there’s an even more outrĂ© possibility: radiation hormesis, the idea that low doses of ionizing radiation are not just (as the data suggest) practically harmless, but actually beneficial. The evidence in favor of it, while not definitive, is actually much more robust than people generally think. In my universe there’s so much nuclear technology and so much exposure to added cosmic radiation by space travelers and colonists we’d probably definitively know either way by now. But imagine if in my timeline it’s shown that radiation hormesis is real. Woo boy.

We already had spas boasting about their wholesomely high radiation levels in the 19th and early 20th centuries (would be funny if they were actually onto something…), but in my universe I could easily see people congregating around nuclear reactors and nuclear explosions (both being in abundance in this world), or even deliberately seeding their environments with radiation-generating nuclear waste (strontium-90 is very cheap, after all). People might even put radioactive material in dietary supplements or even inject it right into their bodies. God, that makes xenoestrogens and mRNA vaccines look like peanuts.

An Alternate History of Birth Control and the Family

Next to gummy vitamins that contain nuclear waste, high explosives, and crack, you’d think hormonal birth control would be no big deal, but the women of this world tend to eschew it in favor of the symptothermal method of fertility awareness. Why bother with the side effects of messing with one’s hormones when the smartphone app is just as easy to manage and just as effective: 99%? Even in real life it never truly took off in popularity in Japan (which preferred condoms) or in the Soviet Union (which preferred abortion), so the idea of pregnancy-mimicking hormones never becoming a mass method of birth control isn’t too far out there.

The social conditions driving our explosion in out-of-wedlock births doesn’t happen either, so you might think traditional family values prevail in this universe. Not so. In this universe the technological, economic, and social conditions are ripe for single motherhood by choice to become a huge movement. After all, in addition to more advanced technology in the field and the much more liberal attitudes around medicine, by the end of the 20th century people are rich enough to not need to work jobs anymore to earn their living. A society of liberal trust fund babies have plenty of wealth and leisure time, obviating any compelling motive aside from personal preference for women to seek a partner to have children with. So we might have about the same rate of out-of-wedlock births and one-parent households as we have now, just at the hands of choice moms rather than dumped ex-girlfriends and divorced mothers.

An Alternate History of Antibiotics?

By now the differences are really adding up. Even something as simple as fighting bacterial infections is different in my fictional universe. In real life have antibiotic drugs, yet phage therapy is a very effective treatment that’s actually older than the likes of penicillin and arguably superior, yet was nearly forgotten about outside the Russian world until very recently. It’s easy to imagine a timeline where phage therapy remains in widespread use, receiving much more patronage than it actually did and greatly advancing the state of the art in the field beyond where it stands in real life today.

Most phages are viruses that eat bacteria, but there are also virophages, viruses that eat other viruses; antiviral phage therapy still has minimal practical use, but that can and likely will expand in the future, and could easily be much further along in some other timeline by now than it is in real life. Phage therapy is yet another alternate-historical aspect I’ve penciled in for my own science-fictional alternate history, even if I have yet to have an occasion to include that in any story I’ve written so far outside the far future of my setting.


It’s a particularly interesting bit of worldbuilding, these therapeutics, and none of this stuff is much if at all beyond present-day technology. I’m not necessarily saying all these technologies and techniques are better than what we use today, but it all does add up to a plausible and rather cool scenario that I’m taking and running with in my alternate-historical setting my stories take place in.

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