Book – Antimicrobials in Society

Histories of Antibiotics

The overall aim of this short project is to uncover some of the socio-historical roots of antibiotic use in both humans and non-humans outside of the European and American histories that are now well understood. We provide an historical account of the arrival and generalisation of use of antibiotics in three Eastern African countries: Zimbabwe, Malawi and Uganda. Drawing upon historical and ethnographic data, we describe when, how and in what context antibiotics arrived in these countries, providing an account of their early uses – both human and non-human. This project follows antibiotics as commodities, investigating how they were inserted within broader markets and the channels through which they were introduced in the African continent.

The project pursues four distinct but interrelated objectives. First, to establish when and which antibiotics were first introduced in each country of focus. We find that this was not so different from Europe: the earliest mentions of antibiotics in Africa date from the mid-1940s, and refer to the same antibiotics that were being discovered and used in the rest of the world. Second, to investigate the context in which antibiotics arrived. We describe this as a set of already-functioning healthcare and veterinary systems, which were established by the colonial governments and missionary organisations throughout the first decades of the twentieth century. Third, to gain insight into the supply chains through which antibiotics were procured and distributed in each country. This was primarily through pharmaceutical companies from the UK and the US, which saw the market opportunities that drugs (and particularly antibiotics) offered in the colonised African territories. Finally, our fourth objective is to explore the actors behind the introduction of antibiotics, and the interests motivating them. We identify these as colonial governments, medical practitioners (private, colonial officers and missionaries) and pharmaceutical companies, who variously worked to ease the healthcare burden, and improve productivity and profit.

Understanding the arrival and further spread of antibiotics in the focus countries can provide important insights about their current use. These findings show how antibiotics and biomedicine came to be associated together. Considering the interests that brought and kept antibiotics in African settings reveals how antibiotics have come to exist in the intersection between health, political agendas, economic interests, cultural identities and international relations. We intend this report to contribute to the development of initiatives to tackle AMR under a One Health framework, expanding the scope to include a diachronic perspective on the health of humans, animals and the environment.

Community Drug Use in Thailand

In 1997 Thailand’s WHO Country Office partially supported the First International Conference on Improving the Use of Medicines or ICIUM in Chiang Mai, Thailand. Over 270 researchers, health system managers, and policy makers from 46 countries around the world gathered and discussed various issues concerning the rational use of drug. The conference found that there was an urgent need of a better understanding on self-medication and the use of medicine in the community. Self-medication with modern pharmaceuticals has been known to be a widespread phenomenon worldwide, but there was an inadequate understanding on how people make decision on self-medication and how modern pharmaceuticals are distributed and utilized in the contexts of local communities.

This report is a result of an attempt to assess the state of knowledge on self- medication and community drug use in Thailand. The research project, entitled “Situation Analysis: Review of Quality Drug Use in the Community,” was undertaken by a multidisciplinary teamwork over a period of one year. In assessing the state of knowledge in this field, special attentions have been paid on the following research questions:

How do people make decisions on self-medication in their life situations in the Thai rural communities?
What kinds of modern pharmaceuticals are available and frequently used in rural communities in Thailand?
How are modern pharmaceuticals distributed and dispensed in rural Thailand?
What is the current situation on regulations and regulative enforcement with regard to the use of modern pharmaceuticals in the community?

With Microbes

Without microbes, no other forms of life would be possible. But what does it mean to be with microbes? With Microbes sets microbes and the multiple ways they exist around, in and on humans at center stage. In this book, 24 social scientists and artists attune to microbes and describe their complicated relationships with humans and other beings. The book shows the multiplicity of these relationships and their dynamism, through detailed ethnographies of the relationships between humans, animals, plants, and microbes. Ethnographic explorations with fermented foods, waste, faecal matter, immunity, antimicrobial resistance, phages, as well as indigenous and scientific understandings of microbes challenge ideas of them being simple entities: not just pathogenic foes, old friends or good fermentation minions, but so much more. By describing these complex, dynamic, and ever-changing entanglements between humans and microbes, the chapters raise crucial points about how microbes are ‘known’ and how social scientists can study microbes with ethnographic methods, more often than not in the absence of microscopes, models, and computations. Following these various entanglements, the book tells how these relations transform both humans and microbes in the process.

At the Limits of Cure

Bharat Venkat’s excellent new book At the Limits of Cure has two key purposes. One is to query our understanding of the idea of “cure,” what it means to be cured or to be healthy, why this is applied to some diseases and not to others, how we conceptualize incurability, and how these ideas change over time and space. He traces the ways in which pain and cure were experienced and were given meaning in people’s social worlds; explores the different ethical, practical, and therapeutic implications of changing treatments; and shows how medical and social calculations of human worth and value often determined who was deemed “worthy” of cure. In unpacking this, Venkat seeks to disrupt the narrative of progress and completion inherent in the notion of cure, showing the “infinity of ends” associated with chronic disease, as health outcomes vary and cures appear to work for a time and then lose impact. The second goal is to situate these concepts in a historical anthropology of tuberculosis treatment in India across the twentieth century, particularly in the light of increasing resistance to antibiotics. Using a wide range of sources — film, mythology, personal narratives, interviews, colonial and medical records, as well as the built environment of the sanatoria — Venkat demonstrates a repeating pattern of new discovery of cure, whether medical or environmental, followed by wider expansion and then gradual disappointment as each attempt fails to reach its initial promise.

Emerging Financial Models for Antibiotic Development (2000-2016)

Antimicrobial resistance (AMR) is a major global health challenge caused by microbes’ increasing ability to resist the antimicrobials we use to control them. The past thirty years have seen a surge of national and international governance frameworks designed to protect the ongoing efficacy of our antimicrobial infrastructures by improving stewardship of existing antimicrobials and boosting research and development (R&D) of new compounds. With international attention and investment in AMR steadily increasing between 2000 and 2016, decision-makers on both sides of the Atlantic experimented with a range of finance models to refill the ’empty antibiotic pipeline’. The diversity of chosen models reflected varying innovation concepts, political contingency, as well as shifting problem diagnoses about where support was most needed. Although a limited number of novel therapies have resulted from increased public and non-profit support, current international reviews show that the overall level of antimicrobial innovation remains insufficient in the face of escalating AMR.

Reconstructing the historical trajectory of these finance models is not crucial when it comes to understanding why reinvigorating antimicrobial R&D has proven so complicated. To preserve this tacit generational knowledge, we invited key decision-makers from across clinical medicine, industry, funders, and international health to participate in a witness seminar on Emerging Financial Models for Antibiotic Development in Geneva in January 2024. The seminar was jointly organised by researchers from the Norwegian Research Council-funded Dry-Antibiotic Pipeline (Dry- AP) project and the Geneva Graduate Institute’s Global Health Centre. Following initial scene-setting by the project’s principal investigators, the seminar consisted of four sessions focusing (1) on the emergence of concerns about the antimicrobial pipeline, (2) the conceptualization of potential R&D solutions, and (3) emerging finance models between 2000 and 2016. This was followed by a final (4) session giving witnesses the opportunity to reflect in more detail on earlier or missed themes. The resulting five-hour discussion provides unprecedented detail on the interconnected world of high-level decision-making on antimicrobial innovation and AMR during a dynamic period of change for Global Health.

Pyrrhic Progress

Pyrrhic Progress analyses over half a century of antibiotic use, regulation, and resistance in US and British food production. Mass-introduced after 1945, antibiotics helped revolutionize post-war agriculture. Food producers used antibiotics to prevent and treat disease, protect plants, preserve food, and promote animals’ growth. Many soon became dependent on routine antibiotic use to sustain and increase production. The resulting growth of antibiotic infrastructures came at a price. Critics blamed antibiotics for leaving dangerous residues in food, enabling bad animal welfare, and selecting for antimicrobial resistance (AMR) in bacteria, which could no longer be treated with antibiotics. Pyrrhic Progress reconstructs the complicated negotiations that accompanied this process of risk prioritization between consumers, farmers, and regulators on both sides of the Atlantic. Unsurprisingly, solutions differed: while Europeans implemented precautionary antibiotic restrictions to curb AMR, consumer concerns and cost-benefit assessments made US regulators focus on curbing drug residues in food. The result was a growing divergence of antibiotic stewardship and a rise of AMR. Kirchhelle’s comprehensive analysis of evolving non-human antibiotic use and the historical complexities of antibiotic stewardship provides important insights for current debates on the global burden of AMR.

Biosocial Worlds

Biosocial Worlds offers a series of anthropological reflections on the relations between human and non-human life. Arguing against a traditional separation of the ‘biological’ and ‘social’, the book explores the spaces in between, with a view to rethinking ‘the biosocial’. The chapters engage with constructions of health and disease in different environments, embracing a more-than-human and biosocial perspective to encourage anthropological engagement with biology beyond deterministic projections.

Of particular relevance to AMR research is Jens Seeberg’s chapter on the biosocial dynamics of multidrug-resistant tuberculosis in India, from a bacterial perspective. He explores the failure of Directly Observed Therapy (DOTs) in terms of interrupted exposure (or contamination) of bacteria to TB treatment, rather than standard public health explanations of inappropriate protocols and, defaulting and non-compliance. Through this analysis, he moves beyond a focus on individual behaviour, to highlight the political economy of health systems and treatments, and their contribution to the development of drug resistance.

The Mushroom at the End of the World

Matsutake is the most valuable mushroom in the world—and a weed that grows in human-disturbed forests across the northern hemisphere. Through its ability to nurture trees, matsutake helps forests to grow in daunting places. It is also an edible delicacy in Japan, where it sometimes commands astronomical prices. In all its contradictions, matsutake offers insights into areas far beyond just mushrooms and addresses a crucial question: what manages to live in the ruins we have made?

A tale of diversity within our damaged landscapes, The Mushroom at the End of the World follows one of the strangest commodity chains of our times to explore the unexpected corners of capitalism. Here, we witness the varied and peculiar worlds of matsutake commerce: the worlds of Japanese gourmets, capitalist traders, Hmong jungle fighters, industrial forests, Yi Chinese goat herders, Finnish nature guides, and more. These companions also lead us into fungal ecologies and forest histories to better understand the promise of cohabitation in a time of massive human destruction.

By investigating one of the world’s most sought-after fungi, The Mushroom at the End of the World presents an original examination into the relation between capitalist destruction and collaborative survival within multispecies landscapes, the prerequisite for continuing life on earth.

When Experiments Travel

The phenomenal growth of global pharmaceutical sales and the quest for innovation are driving an unprecedented search for human test subjects, particularly in middle- and low-income countries. Our hope for medical progress increasingly depends on the willingness of the world’s poor to participate in clinical drug trials. While these experiments often provide those in need with vital and previously unattainable medical resources, the outsourcing and offshoring of trials also create new problems. In this groundbreaking book, anthropologist Adriana Petryna takes us deep into the clinical trials industry as it brings together players separated by vast economic and cultural differences. Moving between corporate and scientific offices in the United States and research and public health sites in Poland and Brazil, When Experiments Travel documents the complex ways that commercial medical science, with all its benefits and risks, is being integrated into local health systems and emerging drug markets.

Providing a unique perspective on globalized clinical trials, When Experiments Travel raises central questions: Are such trials exploitative or are they social goods? How are experiments controlled and how is drug safety ensured? And do these experiments help or harm public health in the countries where they are conducted? Empirically rich and theoretically innovative, the book shows that neither the language of coercion nor that of rational choice fully captures the range of situations and value systems at work in medical experiments today. When Experiments Travel challenges conventional understandings of the ethics and politics of transnational science and changes the way we think about global medicine and the new infrastructures of our lives.

Adriana Petryna is associate professor of anthropology at the University of Pennsylvania. She is the author of the award-winning Life Exposed: Biological Citizens after Chernobyl (Princeton) and the coeditor of Global Pharmaceuticals: Ethics, Markets, Practices.

Death Without Weeping

When lives are dominated by hunger, what becomes of love? When assaulted by daily acts of violence and untimely death, what happens to trust? Set in the lands of Northeast Brazil, this is an account of the everyday experience of scarcity, sickness and death that centres on the lives of the women and children of a hillside “favela”. Bringing her readers to the impoverished slopes above the modern plantation town of Bom Jesus de Mata, where she has worked on and off for 25 years, Nancy Scheper-Hughes follows three generations of shantytown women as they struggle to survive through hard work, cunning and triage. It is a story of class relations told at the most basic level of bodies, emotions, desires and needs. Most disturbing – and controversial – is her finding that mother love, as conventionally understood, is something of a bourgeois myth, a luxury for those who can reasonably expect, as these women cannot, that their infants will live.