Drawing on institutional historical records, interviews and student theses, this article charts the intersection of hospital acquired illness, the emergence of antimicrobial resistance (AMR), environments of armed conflict, and larger questions of social governance in the specific case of the American University of Beirut Medical Center (AUBMC) in Lebanon. Taking a methodological cue from approaches in contemporary scientific work that understand non-clinical settings as a fundamental aspect of the history and development of AMR, we treat the hospital as not just nested in a set of social and environmental contexts, but frequently housing within itself elements of social and environmental history. AMR in Lebanon differs in important ways from the settings in which global protocols for infection control or rubrics for risk factor identification for resistant nosocomial outbreaks were originally generated. While such differences are all too often depicted as failures of low and middle-income countries (LMIC) to maintain universal standards, the historical question before us is quite the reverse: how have the putatively universal rubrics of AMR and hospital infection control failed to take account of social and environmental conditions that clearly matter deeply in the evolution and spread of resistance? Focusing on conditions of war as an organized chaos in which social, environmental and clinical factors shift dramatically, on the social and political topography of patient transfer, and on a missing “meso” level of AMR surveillance between the local and global settings, we show how a multisectoral One Health approach to AMR could be enriched by an answering multisectoral methodology in history, particularly one that unsettles a canonical focus on the story of AMR in the Euro-American context.
Format: Journal
The invisible city
More-than-human, multispecies and animal geographic accounts of the city have tended to focus on large, charismatic and wild organisms, to the detriment of spatially invisible other-than-humans that are central to urban reproduction. At the same time, urban microbial geographies have foregrounded embodied interactions between humans and microorganisms, whether they are symbiotic or pathogenic, often marginalising the material contributions of extracorporeal microbiomes to the urban fabric. Building from these two blindspots, this article focuses on microbial ecologies that live constitutively outside of (other-than-)human bodies and which are intimately caught up in the metabolic intensities and infrastructural environments of the urban realm. There are two key aims: (1) to explore different forms of urban microbial ecologies and (2) to examine their relationships with urban infrastructures and reproduction. My disciplinary lenses are animal geography, microbe studies and urban ecology and my case studies are focused on urban water metabolism. Thus, based on empirical fieldwork on the urban River Lea in East London and supplemented by scientific literature and technical documents, I analyse three urban microbial ecologies that correspond to the urban realms’ ‘extended microbiomes’: those involved in slow sand filtration for the treatment of drinkable water, those involved in sewage treatment via the activated sludge process and those emerging and evolving in disused urban canal infrastructure. These processes spatially manage microbial growth and modulate the distribution of different forms of microbial agency with important effects for the smooth functioning of urban water metabolism. I suggest these ecologies correspond to the ‘spaces’ of microbes in the city, and characterise a mundane system of repetition and regulation. However, microbes continue to assert their agency within the spaces of urban water metabolism, create their own places and worlds and highlight a more-than-human contingency and indeterminacy at the heart of urban reproduction.
Microbes and Marginalisation
Reducing human-microbial encounters through improved infection prevention and control (IPC) is widely acknowledged to be critical for reducing the emergence, transmission and burden of antimicrobial resistance (AMR). However, despite its centrality in the Global Action Plan (GAP) on AMR and adoption as a goal in National Action Plans around the world, there has been limited progress on reducing the incidence of antimicrobial resistant infections globally. In this paper, we argue that closer attention to different faces of AMR could propel progress in this area, with a focus on bedridden people situated in liminal spaces in the Thai health system and suburban economy. Our ethnographic fieldwork followed the cases of 16 bedridden people through the eyes of their carers and medical staff. We ‘descended into the ordinary’ to encounter individuals living – and dying – in the shadows of the labour-intensive suburbs of Bangkok. Here, AMR and IPC protocols are operationalised in the context of competing priorities and pragmatic decision-making. Focussing on three ethnographic vignettes, we use the analytic frames of precarity and care to consider how particular (bedridden) bodies are differentially exposed to AMR infections in the context of economic, social, and political arrangements that structure embodied vulnerabilities and forms and foci of care. Whilst the political work of calculating the burden of AMR may be oriented around galvanising support through a sense of magnitude and generalised risk, this research serves as a reminder that the faces of AMR include those who disproportionately shoulder the global burden of AMR, making it at once exceptional and ordinary.
Antibiotics in pig meat production
For people interested in high-quality food, Italy has long been acknowledged for its production of Parma ham, salami and similar pig meat-based products. For researchers in the field of antibiotic resistance, they are known as products of a highly antibiotic-dependent production system. Italy has one of the highest consumptions of antibiotics by animals in the EU, estimated to be 244 mg/PCU. By contrast, Sweden has the lowest consumption of antibiotics by animals in the EU, estimated to be 12.5 mg/PCU. Thus, the Italian level is about 20 times higher than the Swedish one. The aim of this paper is to pinpoint the role of antibiotics in the Swedish and Italian production systems. What are the underlying forces and the key features of the Swedish production system—a system that can actually compensate for routine group treatment with antibiotics through precautionary health and biosecurity? What aspects are behind the different antibiotic consumption patterns in the Italian setting? We argue that the Swedish ability to compensate for routine prophylactic antibiotic group treatment was the outcome of an extensive interaction process: ‘outsiders’ increased the general awareness of routine antibiotic use by debating it in the media, and ‘insiders’ took the debate seriously and consequently acted to develop a production system that was able to compensate for routine use of antibiotics. Based on both the Swedish and Italian experiences, we argue that a legal ban on routine group treatment does not in itself guarantee a change. Those who are supposed to adopt must first share the ideas the legislation rests on; second, they must be prepared to invest in a change of material structures; third, they must foresee a ‘fair’ distribution of costs and benefits among producers and users—that is, an economic context in which all players are incentivised to follow the same route.
The Invisible Pandemic of Antimicrobial Resistance and Its Possible Ending
Antimicrobial resistance (AMR) is often framed as a ‘silent pandemic,’ an invisible crisis unfolding beyond the public gaze. This unseen emergency narrative fuels policy responses aimed at re-establishing human control over antimicrobial use and benefits. In this commentary, we critique the reduction of AMR to a homogenising framework – a product of long-standing paradigms for disease control and elimination. We argue that AMR stems not merely from microbial exposure to drugs, but also involves broader anthropocentric practices. We assert that merely extending AMR concerns to encompass environmental factors is insufficient. Instead, we advocate for a paradigm shift towards a holistic understanding that respects the evolutionary adaptability and survival strategies of microbial life itself. Consequently, a fundamental re-evaluation of large-scale antibiotic use and production is necessary. Rather than seeking to control AMR as a pandemic, we propose exploring the inherent complexity and interdependence of AMR issues. Our proposition advocates for alternative futures that foster collaborations between human and non-human actors, ultimately envisioning a shift in human-microbial relationships towards more integrative health strategies.
We Use It a Lot for Everything
Increasing rates of antimicrobial resistance has accelerated global efforts to reduce antibiotic use. While antibiotic resistance poses a significant threat, especially in low-income settings, there is a scarcity of research on how people in such environments, including refugee camps, access and use antibiotics. This article explores factors that contribute to the shaping of antibiotic use in Shatila refugee camp in Lebanon. It is based on six months of fieldwork from October 2021 to April 2022 in Shatila, consisting of participant observation, semi-structured interviews and group workshops with 32 camp residents and health workers. Following the onset of the Syrian war in 2011, the number of informal pharmacies and Syrian medicines boomed in Shatila. Aiming to describe and analyze how camp residents access and use antibiotics, we address two main themes: 1) the omnipresence of antibiotics in a context of scarcity, and 2) antibiotics as a panacea – a quick-fix for everyday ailments. Antibiotic consumption patterns in Shatila are formed by a scarcity of quality healthcare services on the one hand, and an omnipresence of antibiotics on the other. We demonstrate that in this loosely regulated context, where pharmaceuticals are bought over-the-counter; there is extensive antibiotic consumption. Camp residents often self-medicate with antibiotics for a wide range of purposes, extending beyond the treatment of infections. The high consumption of antibiotics will increase the level of antimicrobial resistance and pose a risk to the camp residents by disturbing local microbiomes and the amount of resistant genes (the resistome) in the environment, thus leading to new potential health risks. Building on theories of pharmaceuticalization and social suffering, we propose the concept of “antibioticalization.” This distinct form of pharmaceuticalization is characterized by the pervasive and generalized use of antibiotics, especially in contexts of healthcare and resource scarcity.
‘I am my own doctor’
As everyday life in Shatila refugee camp in Lebanon is heavily constrained by structural factors such as poverty, discrimination and limited access to quality healthcare, camp residents find ways to survive – to cope. Through six months of ethnographic fieldwork with participant observation and qualitative interviews in the informal pharmaceutical sector in Shatila, I observed how camp residents use everyday coping tactics to access and use antibiotics; they climb the antibiotic hierarchy, become their own doctors, try different antibiotics through trial and error, and access healthcare and antibiotics for each other in creative ways based on their social networks. These everyday coping tactics illustrate creativity, resilience and agency, which are important factors to consider when creating interventions to reduce antibiotic use in this setting: Shatila residents are not only victims forced to use antibiotics, they can also be actors who take part in shaping the future of Shatila. Antimicrobial resistance (AMR) is a massive threat to health worldwide, especially in low-income settings. Shatila residents should be the ones who develop and implement interventions to reduce antibiotic use in Shatila, as part of decolonising policy making in the field of AMR.
Economies of resistance
The social organisation of economic life plays a pivotal role in assembling many emerging and enduring health problems. Yet throughout the recent history of global health challenges, an emphasis on the influence of economic systems has frequently been sidelined in favour of research that interrogates the behavioural and/or cultural dimensions of these problems. The global crisis of antimicrobial resistance provides a striking example of this trend, with analysis frequently and increasingly focusing on behavioural or technological fixes – for example, the need for responsible use of remaining antimicrobial drugs, or for revived efforts to identify new antimicrobial agents – while at times glossing over the market logics that reproduce the problem itself. With a few notable exceptions, the economic headwinds that shape the current antimicrobial resistance (AMR) scene have been largely decentred in scholarly discussions. In this article, we argue for a critical sociology of economies of resistance, contributing to burgeoning efforts to understand how economic structures both shape the acceleration of AMR and undermine the development of drug and diagnostic solutions.
Waves of Attention
This article uses quantitative and qualitative approaches to review 75 years of international policy reports on antimicrobial resistance (AMR). Our review of 248 policy reports and expert consultation revealed waves of political attention and repeated reframings of AMR as a policy object. AMR emerged as an object of international policy-making during the 1990s. Until then, AMR was primarily defined as a challenge of human and agricultural domains within the Global North that could be overcome via ‘rational’ drug use and selective restrictions. While a growing number of reports jointly addressed human and agricultural AMR selection, international organisations (IOs) initially focused on whistleblowing and reviewing data. Since 2000, there has been a marked shift in the ecological and geographic focus of AMR risk scenarios. The Global South and One Health (OH) emerged as foci of AMR reports. Using the deterritorialised language of OH to frame AMR as a Southern risk made global stewardship meaningful to donors and legitimised pressure on low-income and middle-income countries to adopt Northern stewardship and surveillance frameworks. It also enabled IOs to move from whistleblowing to managing governance frameworks for antibiotic stewardship. Although the environmental OH domain remains neglected, realisation of the complexity of necessary interventions has increased the range of topics targeted by international action plans. Investment nonetheless continues to focus on biomedical innovation and tends to leave aside broader socioeconomic issues. Better knowledge of how AMR framings have evolved is key to broadening participation in international stewardship going forward.
Taking Opportunities, Taking Medicines
The ways in which dimensions of health and healthcare intersect with economics and politics in particular contexts requires close attention. In this article we connect concerns about antibiotic overuse in Uganda to the social milieu created through policies that follow President Museveni’s vision for a population who kulembeka, “tap wealth.” Ethnographic fieldwork in rural Eastern Uganda illustrates how taking medicines in rural households reflects a wider landscape of everyday imperatives to “tap” opportunities in a context of acute precarity. We argue for a closer connection between medical and economic anthropology to push forward understanding of health, medicines and wellbeing in Africa.
