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.
Format: Journal
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.
Decentring antibiotics
It is widely assumed that the development of antibiotics had a transformative effect on livestock production by making it possible to keep larger numbers of animals in smaller spaces without them succumbing to disease. Using the health and production of UK pigs, ca. 1925-65, as a case study, this article argues that their impact has been overstated. It draws on evidence from veterinary journals, farming magazines, and government-appointed committees to demonstrate the significance of other methods of countering the diseases that emerged in association with intensive production systems. Devised by vets, farmers and other experts, these methods predated antibiotics and evolved alongside them. They were rooted in a shared understanding of pig diseases as highly complex phenomena that resulted from interactions between pig bodies and their environments. Recognition of the roles played by housing, husbandry, nutrition, and pathogens in the production of pig disease suggested multiple possible points of intervention. In situating antibiotics within this landscape of disease prevention and control, this article challenges existing claims about their reception and impact, decentres them from the history of intensive farming, and draws attention to other methods of promoting pig health, which may find renewed applications as we move towards a post-antibiotic era.
Antibiotics “dumped”
China and India have become major producers of antibiotics, and the world has become highly dependent on them. Since 2000, the competition among Chinese and Indian manufacturers on key antibiotic ingredients has become increasingly intense in a series of trade disputes involving anti-dumping investigations. Analyzing these trade disputes, we find that they provide a space of communication and contestation where seemingly objective facts about pharmaceutical ingredients are transformed into debatable subjects, which are used and sometimes manipulated by stakeholders of conflicting interests. The disputes reveal entangled configurations and multilayered stakes in the China–India pharmaceutical nexus that often defy polarized national interests. Stakeholders must juggle multiple factors, including public health interests, nationalist sentiments, and corporate profit, in negotiating the national identities and the physical and chemical properties of “standard” pharmaceutical ingredients. The disputes also highlight the coexistence of collaboration and competition among Chinese and Indian stakeholders in global pharmaceutical supply chains.
Stench and sensibilities
Stench is often the most immediate mark of something dirty, decaying and diseased. In India, stench and the smell of acrid smoke commonly indicate the proximity of an open dump or landfill. Frequently a slum is located in the vicinity too, housing waste-pickers who forage in these sprawling dumps for salvageable waste. These spaces are also host to vermin, birds, stray dogs, pigs, cows and, more recently, dangerous bacteria resistant to even top-end antibiotics, popularly known as ‘superbugs’. In this paper I examine the socio-ecological context of neighbourhood, community open garbage dumps and larger landfills in an effort to understand these as part of a dynamic ecosystem of ‘more-than-human’ relations. Perceptual variations of smell as experienced in and around waste (in its solid, liquid and gas states) are intrinsically linked to symbolic and material practices across species. Additionally, I suggest that one productive way to think about the emergence of disease and pathogenicity is by considering the information stimulated by smell, which is mediated by cultural interpretations, biological capacities and wider political economies.
Antimicrobial resistance
This article focuses on the development of veterinary medicine in the industrial pig and poultry production sector. In the current context of controversies over the public problem of antimicrobial resistance (AMR), the veterinary profession is tending to promote a model of preventive medicine that is supposed to reduce the use of antibiotics in livestock farming. However, veterinarians specializing in pig and poultry production (“industrial vets”) have in fact been adopting such approaches to animal health for several decades. Based on 28 interviews with pig and poultry veterinarians practicing or having practiced in western France between the 1970s and the 2010s, the article aims to understand how such a form of professional expertise has developed, and the business model that underpins it. Contrary to public discourses which promote preventive approaches as a way to diversify professional expertise and to disconnect veterinary incomes from drug sales, it is indeed this economic model that has allowed the development of such approaches within industrial livestock farming. Modern strategies for reducing antibiotic use should therefore seek less to renew the professional expertise of veterinarians than to find new ways to valorize it economically.
