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.
Format: Journal
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.
Treating Mycoplasma genitalium (in pregnancy)
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.
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.
