Antimicrobial Resistance is a threat to individual and to population health and to future generations, requiring “collective sacrifices” in order to preserve antibiotic efficacy. ‘Who should make the sacrifices?’ and ‘Who will most likely make them?’ are ethical concerns posited as potentially manageable through Antimicrobial Stewardship. Antimicrobial stewardship almost inevitably involves a form of clinical cost-benefit analysis that assesses the possible effects of antibiotics to treat a diagnosed infection in a particular patient. However, this process rarely accounts properly for patients – above and beyond assessments of potential (non)compliance or adherence to care regimes. Drawing on a vignette of a pregnant woman of colour and migrant diagnosed with Mycoplasma genitalium, a sexually transmissible bacterium, this article draws out some of the ethical, speculative, and practical tensions and complexities involved in Antimicrobial Stewardship. We argue that patients also engage in a form of cost-benefit analysis influenced by experiences of reproductive and social (in)justice and comprising speculative variables – to anticipate future possibilities. These processes have the potential to have effects above and beyond the specific infection antimicrobial stewardship was activated to address. We contend that efforts to practice and research antimicrobial stewardship should accommodate and incorporate these variables and acknowledge the structures they emerge with(in), even if their components remain unknown. This would involve recognising that antimicrobial stewardship is intricately connected to other social justice issues such as immigration policy, economic justice, access to appropriate medical care, racism, etc.
Format: Journal
Antibiotics and the Biopolitics of Sex Work in Zimbabwe
The advent of antibiotics transformed the global public health landscape, dramatically improving health outcomes. Drawing on historical and ethnographic research on sex work in Zimbabwe, we examine the role of antibiotics in the management of sexually transmitted infections among sex workers, from punitive colonial approaches to “empowerment”-based discourses. We illustrate how programs for sex workers, while valued by these women, are narrow, exclusionary, and enact a pharmaceuticalized form of governance that hangs on the efficacy of antibiotics. With antibiotics’ efficacy under threat, we consider how latent colonial logics are in danger of being reactivated to control both infections and women.
The Changing Management of Acute Bronchitis in Britain, 1940–1970
It has become commonplace in accounts of medicine in the second half of the twentieth-century to ascribe an “antibiotic revolution” to the years when penicillin became widely available from the early 1950s. However, to date there have been hardly any studies that demonstrate a major discontinuity in medical practices after mid-century, let alone that go on to specify their character. There would seem to be two key features of any “antibiotic revolution”: first and foremost that the treatment of diseases was transformed as doctors were able to cure illness caused by infections with specific drugs that eliminated causative bacteria; and second that the ambition of doctors to intervene with drugs in a number of diseases grew, as did the ability of the pharmaceutical industry to supply an increasing range of targeted and effective remedies. In this article we contribute towards an assessment of the first of these key features by discussing the changing management of acute bronchitis from the mid-1940s to the early 1960s. The disease was amongst the most prevalent and important of that period in Britain, being the single largest cause of consultations with general practitioners (GPs) through much of the 1950s. Bronchitis was also the subject of many high profile debates among doctors and health care agencies as concerns about its morbidity and mortality touched on such issues as smoke pollution, the costs of the National Health Service (NHS) and changes in the doctor–patient relationship. The evidence of contemporary studies shows that the treatment of acute bronchitis changed radically after the introduction of antibiotics, such that by the mid-1950s over 80 per cent of patients diagnosed with the condition were prescribed penicillin or another antibacterial drug—a shift that was not supported by any clinical trials or systematic evidence. How and why this change occurred are the questions we set out to answer.
Filth and the City
Filth is a material and a semiotic category that has long been used to classify and govern the human and the nonhuman world. Undesired social groups and forms of life are elided with disgusting elements of the environment to justify their suppression or eradication. The science and the management of filth have been central to modernity and have profoundly shaped urban life. The rise of microbiology revealed the microbial origins of some diseases, empowering visions of the sanitary city in both the metropole and the colony. This drove substantial investments in sanitation, hygiene, and the removal of animals and agriculture. However, recent research on the human microbiome has demonstrated the salutary role of some microbes for human well-being. It highlights the value of forms of material previously categorized as filth and calls for a recalibration of modern, antibiotic hygiene practices and modes of architecture and urban planning. This new microbiology is driving a nascent, probiotic turn in urban theory that overlaps with a wider appreciation of the beneficial role of nature in the urban environment, and the development of more affirmative models of urban hospitality premised on living with social difference. This review and perspective examines these connected developments, explores their implications for urban political ecology, and outlines a new research agenda. It starts with a chronology of the shifting material and semiotic relationships with filth in science and society, before identifying six key research questions to guide an interrogation of this new chapter in the storied history of filth and the city.
Countering the Logics of War in Global Health Policy
Powerful pharmaceuticals are readily available for purchase throughout Tanzania and global health policy makers decry this situation as dangerous and disordered, as if no rules govern the use of drugs in Africa. In the prevailing global health understanding, ‘truth’ lies in the laboratory science that goes into the making and proper prescription of drugs, and such deviations as ‘overuse’ and ‘misuse’ result from the fact that locals supposedly misunderstand what these drugs are and how they should be used. However, my ethnographic research in Tanzania reveals that embodied epistemologies frequently enable medical practitioners and patients to evaluate the quality of various drugs and to identify chakachua (substandard or adulterated) pharmaceuticals through their material and sensory qualities—a practice I conceptualize as a form of ‘fugitive science’ (Rusert Citation2017). In light of this, I analyze the WHO’s National Action Plan for Antimicrobial Resistance in Tanzania, demonstrating how such global health policies disregard this knowledge, employing neocolonial rhetoric that presents ‘ignorance’ and ‘lack of hygiene’ as the sources of growing antimicrobial resistance while simultaneously obscuring structural inequalities. I argue that such forms of global health surveillance operate through the logics and epistemologies of war (Chow Citation2006; Terry Citation2017) in ways that render populations in the Global South into threats and targets. I conclude by suggesting that fugitive science can work as counter-evidence to health security frameworks and, as such, represents a furtive form of resistance to these militarized logics.
Antimicrobial prescribing matters
Antimicrobial resistance caused by widespread use of antimicrobials is a defining challenge of our time. This article presents antimicrobial prescribing among physicians as a morally irreconcilable endeavour. Particularly, the physician may have no good option when antimicrobial resistance is seen as both (1) a global threat to be addressed at the population level, and (2) a threat to the individual patient to be addressed in clinical practice. This research demonstrates that in practice, the physician is presented with an irreconcilable dilemma between caring for the population or caring for the individual. The author utilizes an extended ethnographic case study of infectious disease specialists to show that physicians are pressured to use antimicrobials more responsibly for the benefit of society, yet at the same time treat the individual patients with care by administering the most effective and appropriate agents. The author concludes by suggesting that there is no straightforward answer for the practicing physician, since what ultimately matters is unlikely to satisfy either moral ranking system.
Microbial semiotics
As I was wrapping up fieldwork in Guatemala in late 2021, I encountered and saved an advertisement circulating on Instagram (Figure 1). It displayed a series of images of medications beginning with a box of azithromycin, a broad-spectrum antibiotic used to treat various bacterial infections. The ad was sponsored by Paiz, a Mexican and Central American subsidiary of Walmart, which took advantage of the Instagram Shopping feature: a big red “shop now” button that takes viewers to sites where they can purchase the advertised products. In this post, the price was 15 Guatemalan quetzals (approximately 2 USD) for 30 500-mg tablets of azithromycin. The accompanying caption proclaimed, “Contamos con más surtido para que en tu alacena siempre tengás lo que te gusta” (We offer a greater selection so that you can always have whatever you like in your cupboard). A white label with a red sticker adorned the box. Its small lettering only became legible upon zooming in, reading, “ESTE PRODUCTO SE VENDE SOLO CON RECETA MÉDICA” (This product is sold only with a medical prescription.) Despite the antibiotic’s advertised availability, this fine print reflected recent efforts to limit its unrestricted sale in Guatemala. As part of a strategy for combatting rising rates of antibiotic resistance, the Guatemalan Ministry of Public Health and Social Assistance (MSPAS) issued a decree (acuerdo ministerial 145–2019) in June 2019 prohibiting nonprescription sales of antibiotic medications. This was also part of a broader effort among global health institutions and national governments to develop strategic action plans to address antibiotic resistance (Patel et al., 2023).
Life as Aftermath
Anthropogenic pressures now shape the development, interrelations, and evolution of microbes, plants, animals, and humans. In an age of oxidative stress and failures of DNA repair, cytokine storms and microbial dysbiosis, social scientific theory stutters in the face of biological consequences of forces it masterfully detailed, from biopower to looping kinds. Concepts of the fallibility of knowledge from the unanticipated consequence to the wicked problem are too generic to fathom the nature of the living within reconfigured biotic-abiotic relations in the aftermath of industrialization. Working through examples—genetic modification in weed control, and solvents in cryobiology—this paper offers a novel analytic for anthropogenic biology specific to the relations between knowledge and life in the wake of the industrial twentieth century: a novel patterning of living matter and process from the molecular to the ecological arising with forms of biological control. Changes in pathogens and hosts, targets and bystanders are specific to the form of control but not anticipated by it, illegible within its originating logics. Hubris gone moldy, anthropogenic biology grows from forms of power that overestimate the comprehensiveness of their own efficacy, mistaking the ability to temporarily control living things for full knowledge of them.
Negotiating authoritarian law and (dis)order
Global health policymakers have identified Myanmar as a source of high drug resistance and informal pharmaceutical markets in need of tighter state regulation. The World Health Organization drafted a Global Action Plan on antibiotic resistance (often referred to as antimicrobial resistance) that seeks to address it. Myanmar is one of over a hundred countries that has followed the World Health Organization’s prescription and drafted its own National Action Plan. Through participating in the everyday life of a family pharmacy, we observed that in practice the outcomes of global plans for AMR, such as regulating access to antibiotics, are shaped by people’s limited access to affordable health care, low salaries, and the military’s authoritarian role in Myanmar politics. We followed how negotiations between state officials and drug vendors evolved towards a mutual understanding (as opposed to following written rules) after a Food and Drug Administration raid, intended to enforce the regulation of the sales of illegal medicines. Rather than uncritically pushing state-centric action, those working to promote the regulation of medicines must attend more carefully to how different modes of political authority and governance, combined with histories of health provision, shape drug policy in practice. Otherwise, they risk contributing, if not intensifying, already existing health and social injustices, whilst also failing to generate their intended outcomes, such as meaningful changes to antibiotic sales and reductions in resistance.
Pharmaceuticalised livelihoods
The ‘livestock revolution’ has seen the lives and livelihoods of peri-urban peoples increasingly intertwine with pigs and poultry across Africa in response to a rising demand for meat protein. This ‘revolution’ heralds the potential to address both poverty and nutritional needs. However, the intensification of farming has sparked concern, including for antibiotic misuse and its consequences for antimicrobial resistance (AMR). These changes reflect a micro-biopolitical conundrum where the agendas of microbes, farmers, publics, authorities and transnational agencies are in tension. To understand this requires close attention to the practices, principles and potentials held between these actors. Ethnographic research took place in a peri-urban district, Wakiso, in Uganda between May 2018 and March 2021. This included a medicine survey at 115 small- and medium-scale pig and poultry farms, 18 weeks of participant observation at six farms, 34 in-depth interviews with farmers and others in the local livestock sector, four group discussions with 38 farmers and 7 veterinary officers, and analysis of archival, media and policy documents. Wide-scale adoption of quick farming was found, an entrepreneurial phenomenon that sees Ugandans raising ‘exotic’ livestock with imported methods and measures for production, including antibiotics for immediate therapy, prevention of infections and to promote production and protection of livelihoods. This assemblage – a promissory assemblage of the peri-urban – reinforced precarity against which antibiotics formed a potential layer of protection. The paper argues that to address antibiotic use as a driver of AMR is to address precarity as a driver of antibiotic use. Reduced reliance on antibiotics required a level of biosecurity and economies of scale in purchasing insurance that appeared affordable only by larger-scale commercial producers. This study illustrates the risks – to finances, development and health – of expanding an entrepreneurial model of protein production in populations vulnerable to climate, infection and market dynamics.
