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.
Format: Journal
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.
Negotiating hospital infections
This paper reviews and contrasts two strategies of infection control that emerged in response to the growing use of antibiotics within British hospitals, c.1946-1969. At this time, we argue, the hospital became an arena within which representatives of the medical sciences and clinical practices contested not so much the content of knowledge but the way that knowledge translated into practice. Key to our story are the conceptual assumptions about antibiotics put forward by clinicians, on the one hand, and microbiologists on the other. The former embraced antibiotics as the latest weapon in their fight to eradicate disease. For clinicians, the use of antibiotics were utilised within a conceptual frame that prioritised the value of the individual patient before them. Microbiologists, in contrast, understood antibiotics quite differently. They adopted a complex understanding of the way antibiotics functioned within the hospital environment that emphasised the relational and ecological aspects of their use. Despite their broader environmental focus, microbiologists focus on the ways in which bacteria travelled led to ever greater emphasis to be placed on the “healthy” body which, having been exposed to antibiotics, became a dangerous carrier of resistant staphylococcal strains. The surrounding debate regarding the appropriate use of antibiotics reveals the complex relationship between hospital, the medical sciences and clinical practice. We conclude that the history of hospital infections invites a more fundamental reflection on global hospital cultures, antibiotic prescription practices, and the fostering of an interdisciplinary spirit among the professional groups living and working in the hospital.
Food supply chains and the antimicrobial resistance challenge
This paper presents a critique of supply chain responses to a particular global wicked problem – antimicrobial resistance (AMR). It evaluates the understanding of AMR (and drug-resistant infections) as a food system challenge and critically explores how responsibility for addressing it is framed and implemented. We place the spotlight on the AMR strategies applied in UK retailers’ domestic poultry and pork supply chains. This provides a timely analysis of corporate engagement with AMR in light of the 2016 O’Neill report on Tackling Drug Resistant Infections Globally, which positioned supermarket chains, processors, and regulators as holding key responsibilities. Research included interviews with retailers, industry bodies, policy makers, farmers, processors, consultants and campaigners. We evaluate how strategy for tackling AMR in the food system is focused on antimicrobial stewardship, particularly targets for reducing antibiotic use in domestic food production. The global value chain notion of multipolar governance, where influence derives from multiple nodes both inside and outside the supply chain, is blended with more-than-human assemblage perspectives to capture the implementation of targets. This conceptual fusion grasps how supply chain responsibility and influence works through both a distributed group of stakeholders and the ecological complexity of the AMR challenge. The paper demonstrates in turn: how the targets for reducing antibiotic use in domestic meat production represent a particular and narrowly defined strategic focus; how those targets have been met through distributed agency in the UK supply chain; and the geographical and biological limitations of the targets in tackling AMR as a wicked problem.
Current Accounts of Antimicrobial Resistance: Stabilisation, Individualisation and Antibiotics as Infrastructure
Antimicrobial resistance (AMR) is one of the latest issues to galvanise political and financial investment as an emerging global health threat. This paper explores the construction of AMR as a problem, following three lines of analysis. First, an examination of some of the ways in which AMR has become an object for action—through defining, counting and projecting it. Following Lakoff’s work on emerging infectious diseases, the paper illustrates that while an ‘actuarial’ approach to AMR may be challenging to stabilise due to definitional and logistical issues, it has been successfully stabilised through a ‘sentinel’ approach that emphasises the threat of AMR. Second, the paper draws out a contrast between the way AMR is formulated in terms of a problem of connectedness—a ‘One Health’ issue—and the frequent solutions to AMR being focused on individual behaviour. The paper suggests that AMR presents an opportunity to take seriously connections, scale and systems but that this effort is undermined by the prevailing tendency to reduce health issues to matters for individual responsibility. Third, the paper takes AMR as a moment of infrastructural inversion (Bowker and Star) when antimicrobials and the work they do are rendered more visible. This leads to the proposal of antibiotics as infrastructure—part of the woodwork that we take for granted, and entangled with our ways of doing life, in particular modern life. These explorations render visible the ways social, economic and political frames continue to define AMR and how it may be acted upon, which opens up possibilities for reconfiguring AMR research and action.
Seeing Green
Medical professionals’ and policymakers’ fear of antimicrobial resistance (AMR) has largely been directed toward antibiotic use in medicine and animal agriculture. In Thailand, however, the use of antibiotics in citrus orchards has raised some concern over their ‘appropriateness’ and there have been calls for reduction—if not complete cessation—of their usage. We explore the emergence of antibiotic use for citrus greening disease (CGD) as part of shifting assemblages of plants, pests, pathogens, and people, as well as of varying climates, technologies, and farming practices. We suggest that rather than being a threat coming from outside orchards, CGD pathogenicity repeatedly emerges from within, and in Thailand appears to have increased alongside, the intensification of agricultural practices. We document how, when antibiotics emerged in the mid-20th century, their ‘pharmaceutical efficacy’ was insufficient to trigger their widespread adoption. Rather, the pharmaceuticalisation of orchards continues to be entangled with the expansion and intensification of mandarin agriculture, and also with the affordability of antibiotics, dissemination of relevant knowledge, and availability of equipment for their injection. Current proposals to reduce antibiotic use risk not taking sufficiently seriously the importance of their role in sustaining intensive orchard practices—and profits.
Postcolonial Global Health, Post-Colony Microbes, and Antimicrobial Resistance
Rather than ‘superbugs’ signifying recalcitrant forms of life that withstand biomedical treatment, drug resistant infections emerge within and are intricate with the exercise of social and medical power. The distinction is important, as it provides a means to understand and critique current methods employed to confront the threat of widespread antimicrobial resistance. A global health regime that seeks to extend social and medical power, through technical and market integration, risks reproducing a form of triumphalism and exceptionalism that resistance itself should have us pause to question. An alternative approach, based on a postcolonial as well as a ‘post-colony’ approach to health and microbes, provides impetus to challenge the assumptions and norms of global health. It highlights the potential contribution that vernacular approaches to human and animal health can play in altering the milieu of resistance.
