Journal – Page 3 – Antimicrobials in Society

Between superimposition and local initiatives

Mitigating antimicrobial resistance (AMR) is a global imperative. Part of this effort is the translation of the Global Action Plan into National Action Plans on AMR (NAPs-AMR). However, effective implementation of these plans remains a governance challenge worldwide. This study aims to explore the apparent implementation gap as a governance problem in Austria by examining the situated perspectives of key experts and stakeholders involved in AMR-related policy and practice. Data were collected through semi-structured qualitative interviews, a focus group discussion, and participation in various symposia on AMR. Data analysis revealed key themes the experts have identified as decisive factors shaping AMR governance, which they perceive as insufficient. These include: the absence of a binding legal framework, incomplete and lacking AMR data, low risk perception, lack of funding mechanisms, and absence of an incentive system for people working in AMR stewardship.

The interpretation of these findings suggests policy fragmentation, scattered responsibilities, agenda conformity and a lack of symbolic and material recognition as central features that impede a comprehensive, sustainable and effective AMR-related governance. These insights highlight a tension between local efforts to precipitate longer-term adaptations to prepare for and mitigate effectively AMR on the one hand, and the current approach of ‘superimposing’ reforms onto existing institutional structures. Effective and sustainable measures to address AMR require a fundamental restructuring process of institutional responsibilities, professional routines, and social practices to prioritize AMR stewardship as a guiding principle.

Wars & Sweets

Once upon a time, many of us moderns dreamt that our future was bright, squeaky clean, germ-free. Now, we increasingly fear that bacterial resistance movements and hordes of viruses are cancelling our medicated performances, and threatening life as many of us have come to know it. In order for our modern antibiotic theatre of war to go on, we pray for salvation through our intensive surveillance of microbes, crusades for more rational antibiotic wars, increased recruitment of resistance fighters and development of antibiotic armaments through greater investment in our medical-industrial-war complex. But not all of us are in favour of the promise of perpetual antimicrobial wars, no matter how careful or rational their proponents aspire to be. An increasing vocal and diverse opposition has amassed in academic journals, newspapers and other fields of practice denouncing medicalisation and pharamceuticalisation of our daily lives, as well as our modern medicine as overly militaristic. In this paper, rather than simply rehearsing many of these well-made and meaning debates to convert you to yet another cause, I enrol them in redescriptions of our modern medical performances in the hope of awakening you from your aseptic dream. What follows is my invitation for you to re-enact our mythic antibiotic era in all its martial g(l)ory. I promise that it will bring you no physically harm, yet I can’t promise it will leave your beliefs unscathed, as you follow its playful redescription of how our objective scientific descriptions, clinical prescriptions, economic strategies, political mandates and military orders, not to mention our warspeak, have always been deeply entangled with triumphs and devastations of The(ir) Great anti-Microbial Wars (aka our antibiotic era).

Regulating antimicrobial resistance

Antimicrobial resistance (AMR) has become one of the defining challenges of the twenty-first century. Food production and farming are a key if troubling component of that challenge. Livestock production accounts for well over half of annual global consumption of antimicrobials, though the contribution of the sector to drug resistance is less clear. As a result, there is an injunction to act in advance of incontrovertible evidence for change. In this paper we engage with the role of market actors in the precautionary regulation of farming practices and AMR threats. The paper takes the UK poultry sector as exemplary of an audit-led process that has, in recent years, achieved impressive reductions in antimicrobial use. Using qualitative interview data with farmers and veterinarians we chart the changing practices that have accompanied this reduction in treatments. We use this analysis to raise some cautions around audit-led systems of regulation. Audits can lock farms and animals into particular versions of farming and animal health; they can elevate harmful compensatory practices (including disinfectant uses); and they can reproduce an actuarial approach to an issue that does not fit the conventions of risk management. The paper presents the considerable successes that have been achieved over a short period of time in a livestock sector, while generating notes of caution concerning the audit-led management of livestock-related AMR threats.

Pharma-cartography

Antibiotic resistance threatens provision of healthcare and livestock production worldwide with predicted negative socioeconomic impact. Antibiotic stewardship can be considered of importance to people living in rural communities, many of which depend on agriculture as a source of food and income and rely on antibiotics to control infectious diseases in livestock. Consequently, there is a need for clarity of the structure of antibiotic value chains to understand the complexity of antibiotic production and distribution in community settings as this will facilitate the development of effective policies and interventions. We used a value chain approach to investigate how relationships, behaviours, and influences are established during antibiotic distribution. Interviews were conducted with key informants (n = 17), value chain stakeholders (n = 22), and livestock keeping households (n = 36) in Kolkata, and two rural sites in West Bengal, India. Value chain mapping and an assessment of power dynamics, using manifest content analysis, were conducted to investigate antibiotic distribution and identify entry points for antibiotic stewardship. The flow of antibiotics from manufacturer to stockists is described and mapped and two local level maps showing distribution to final consumers presented. The maps illustrate that antibiotic distribution occurred through numerous formal and informal routes, many of which circumvent antibiotic use legislation. This was partly due to limited institutional power of the public sector to govern value chain activities. A ‘veterinary service lacuna’ existed resulting in livestock keepers having higher reliance on private and informal providers, who often lacked legal mandates to prescribe and dispense antibiotics. The illegitimacy of many antibiotic prescribers blocked access to formal training who instead relied on mimicking the behaviour of more experienced prescribers–who also lacked access to stewardship guidelines. We argue that limited institutional power to enforce existing antibiotic legislation and guide antibiotic usage and major gaps in livestock healthcare services make attempts to curb informal prescribing unsustainable. Alternative options could include addressing public sector deficits, with respect to both healthcare services and antibiotic provision, and by providing resources such as locally relevant antibiotic guidelines to all antibiotic prescribers. In addition, legitimacy of informal prescribers could be revised, which may allow formation of associations or groups to incentivise good antibiotic practices.

Controlling Bacteria in a Post-antibiotic Era

This article addresses people’s experiences with bacteria and the human body and examines the cultural meanings regarding concerns that society likely is running out of effective antibiotics. The empirical material comes from Sweden, and our analysis is framed through perspectives from the medical humanities. The interdisciplinary goal is to better understand the societal challenges of antibiotic resistance in the advent of a so-called post-antibiotic era. The study presents results from the “If antibiotics stop working” questionnaire which was distributed with the help of The Folklife Archives with the Scania Music Collections at Lund University. We argue that the concept of a post- antibiotic era can open a more imaginary way of thinking about what future relationships are possible if antibiotics were to lose their curative power.

The ‘Drug Bag’ method

Understanding the prevalence and types of antibiotics used in a given human and/or animal population is important for informing stewardship strategies. Methods used to capture such data often rely on verbal elicitation of reported use that tend to assume shared medical terminology. Studies have shown the category ‘antibiotic’ does not translate well linguistically or conceptually, which limits the accuracy of these reports. This article presents a ‘Drug Bag’ method to study antibiotic use (ABU) in households and on farms, which involves using physical samples of all the antibiotics available within a given study site. We present the conceptual underpinnings of the method, and our experiences of using this method to produce data about antibiotic recognition, use and accessibility in the context of anthropological research in Africa and South-East Asia. We illustrate the kinds of qualitative and quantitative data the method can produce, comparing and contrasting our experiences in different settings. The Drug Bag method can produce accurate antibiotic use data as well as provide a talking point for participants to discuss antibiotic experiences. We propose it can help improve our understanding of antibiotic use in peoples’ everyday lives across different contexts, and our reflections add to a growing conversation around methods to study ABU beyond prescriber settings, where data gaps are currently substantial.

Self-medication with antibiotics in Maputo, Mozambique

Self-medication, as a form of self-care, is a common practice worldwide, and often involves the use of both over-the-counter and prescription-only medicines, including antibiotics, anti-malarials and others. Increasing concerns over the global emergence and spread of antimicrobial resistance point to the need to reduce and optimise the use of antimicrobial medicines, both in human and animal health. Over the past few decades, numerous studies on self-medication with antibiotics have sought to determine the prevalence, risks and/or factors related to ‘inappropriate’ use in different parts of the world. Yet much of this literature tends to follow a rather normative approach, which regards such practices as problematic and often irrational, frequently overlooking structural aspects, situated circumstances and individuals’ own reasoning. Based on a mixed methods social science research project in Maputo, which included a household survey, observations in pharmacies and interviews with users and healthcare providers, this paper aims to discuss self-medication in light of local users’ everyday practical reasoning. While situating self-medication within local contextual contingencies, the analysis highlights the ways in which personal and socially shared experiences, articulated with forms of knowledge and information provided by different sources, shape and inform practices of and attitudes towards self-medication with antibiotics. By looking at self-medication beyond (non-)prescription use, and by examining individuals’ decisions within their socioeconomic and therapeutic landscapes in Maputo, this study sheds light on the structural and relational factors that contribute to certain consumption practices that do not always follow biomedical recommendations of ‘rational’ or ‘appropriate’ use, helping to deconstruct and further problematise the various legitimate meanings and understandings of ‘responsible’ use.

Antibiotic resistance, planetary health and the mimetic trap

The industrialization of food production over the past century has triggered a series of sanitary crises related to antibiotic resistance. In this article, I contend that to understand the radical transformation of animal farming and its effects on public health, we need to inquire into the historical development of the knowledge on microbes, especially with regard to the agricultural industry’s mobilization and repression of microbial metabolism to scale up food production. Moreover, I conceive of the so-called Great Acceleration of the Anthropocene as a postcolonial mimetic trap through which actors who didn’t play an active role in the contemporary ecological collapse are subsumed into an indistinct ‘we’. To disentangle this alleged collective subject created from accounts of planetary health, I focus on the scientific, social, and institutional histories of antibiotic production and antibiotic use that materialized in the epidemiological issue of antibiotic resistance. Furthermore, I highlight how the history of antibiotic use and resistance is intertwined with the ecological, social, and geopolitical dynamics created by intense industrial production and international rivalries during the Cold War. This article calls for the re-evaluation and creation of counter-narratives of the planetary impact of industry on microbes, local communities, patients, medical personnel, and the global poor.

Phage therapy as a potential solution in the fight against AMR

Phage therapy, the use of bacteriophage viruses to treat bacterial infections, has existed for more than a hundred years. However, the practice is struggling to develop, despite growing support over the past 15 years from researchers and doctors, who see it as a promising therapy in the context of the rise of antimicrobial resistance (AMR). While the reasons for these developmental difficulties are complex, in this article we wish to address the effects of pharmaceutical regulations on phage therapy. By showing how phages are assimilated to an umpteenth antibiotic in legal texts, but also in certain medical practices, this article proposes to analyze the consequences of such regulatory categorization both for their production and the logistics of administration of proof of their efficacy in randomized controlled trials (RCTs), as well as the underlying concepts of infection and treatment. This paper follows Chandler’s work on the concept of antibiotics as infrastructure and its inversion presented by antimicrobial resistance. Phages as living, dynamic, evolving, and specific entities, do not lend themselves easily to current categories, norms, and development models. In this sense, they act as disruptors, revealing the limitations imposed by the existing infrastructure. More precisely here, and to continue Chandler’s initial thought process, this paper aims to show that antibiotics also form a kind of epistemological infrastructure, which acts as a powerful inhibitor to the development of phage therapy. In this sense antibiotics prevent the development of solutions to the problem they contribute to create. But the difficulties phage therapy faces, as highlighted in this article, can be interpreted as entry points for thinking of another medicine and imagining other possible futures. This analysis is based on a 3-year fieldwork study (2016–2019) in Europe (France, Belgium, and Switzerland), during which we conducted semi-directed interviews with various phage therapy stakeholders (physicians, researchers, pharmacists, regulators, patients, and patient associations), participatory observation in labs and observations during symposia and workshops on phages and phage therapy.

AMR survivors?

Behind the statistics forecasting millions of deaths associated with antimicrobial resistance (AMR) is an even greater burden of morbidity leaving many people with long-term chronic illnesses and disability. Despite growing recognition of the importance of inter-sectoral and inter-disciplinary knowledge in forming responses to address this global health threat, there remains a paucity of social science research to understand the social burdens of AMR. In this qualitative study we explore the experiences of people living with chronic AMR infections, their interactions with health providers and therapeutic quests for care, and the effects upon their lives and that of their families and caregivers. Our analysis reveals that the resistant infections impacted not only the physical health but also the mental health of the sufferers and their caregivers, causing major disruptions to their social and work lives. Most undertook arduous treatment regimes – of powerful antibiotics with debilitating side effects, combined a range of other complementary and alternate therapies, including travel to seek treatment overseas. Further, we question the notion of ‘AMR survivorship’ currently being promoted as part of a public education campaign by the World Health Organisation and whether people with the diverse AMR experience really self-identify as ‘survivors’ of a biosocial group.