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.
Format: Journal
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.
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.
