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.
Format: Journal
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.
Antibiotics, Rational Drug Use and the Architecture of Global Health in Zimbabwe
Rising concerns around antimicrobial resistance (AMR) have led to a renewed push to rationalise antibiotic prescribing in low- and middle-income countries (LMICs). There is increasing unease in conceptualising antibiotic use as individuals behaving ‘(ir)rationally’, and recognition that rising use is emergent of and contributing to wider economic and political challenges. But in between these individual and societal level ‘drivers’ of antibiotic use is an everyday articulation of care through these substances, written-in to the scripts, delivery chains and pedagogics of global healthcare. This article focuses on these everyday ‘architectures’ that over time and across spaces have knitted-in antibiotics and rhetorics of control that inform current responses to AMR. Based on historically informed ethnographic research in Zimbabwe, we examine points of continuity and change between 20th Century rational drug use (RDU) discourses and contemporary socio-political formations around AMR and antimicrobial stewardship (AMS), paying particular attention to their co-evolution with the process of pharmaceuticalisation. We illustrate how the framework and techniques of RDU were embedded within programmes to increase access to essential medicines, and as such complemented Zimbabwe’s building of one of Africa’s strongest postcolonial health systems. Whilst RDU was focused on securing health and safety of patients and affordability for systems, AMS programmes aim to secure medicines. Continuous across both RDU and AMS programmes is the persistent rhetoric of ‘irrational use’ by frontline prescribers. Health workers in Harare are attuned to the values and language of these programmes, but their everyday practice follows an architecture in which antibiotics have been designed-in. This research illustrates the struggle to optimise antibiotic use within current framings for action. We propose a reconfiguring of the architecture of global health such that frontline prescribers are able to provide ‘good’ care without necessarily turning to antibiotics. To design-out antibiotic reliance would require attention beyond rationality, to the redrafting of blueprints that inscribe practice.
Air Care: an ‘aerography’ of breath, buildings and bugs in the cystic fibrosis clinic
With significant relevance to the Covid-19 pandemic, this paper contributes to emerging ‘aerographic’ research on the socio-materialities of air and breath, based on an in-depth empirical study of three hospital-based lung infection clinics treating people with cystic fibrosis. We begin by outlining the changing place of atmosphere in hospital design from the pre-antibiotic period and into the present. We then turn to the first of three aerographic themes where air becomes a matter of grasping and visualising otherwise invisible airborne infections. This includes imagining patients located within bodily spheres or ‘cloud bodies’, conceptually anchored in Irigaray’s thoughts on the ‘forgetting of the air’ and Sloterdijk’s immunitary ‘spherology’ of the body. Our second theme explores the material politics of air, air conditioning, window design, and the way competing ‘air regimes’ come into conflict with each other at the interface of buildings, bodies and the biotic. Our final theme attends to the ‘cost of air’, the aero-economic problem of atmospheric scarcity within modern high-rise, deep-density healthcare architectures.
The Charm of Medicines
Even amongst biomedical scientists, medicines have an enigmatic air, for example in the way they are often referenced as ‘magic’ bullets. In reference to antimicrobials, ‘magic’ evokes both the power and potential super-power of such substances and their relations to our material and social realities. Moving this further, anthropologists Sjaak van der Geest and Susan Reynolds Whyte describe medicines as having ‘charm’, providing a concrete solution to ill- health, and an effect that can be separated from a therapeutic encounter. This distinguishes medicines from other forms of healing such as surgery, which cannot be separated from a surgeon.
Medicines are democratic and exoteric, they are ‘widely believed to contain the power of healing in themselves. Anyone who gains access to them can apply their power’ (Van der Geest & Whyte, 1989 p346). The authors extended this perspective to incorporate a wide range of places and spaces where medicines flow, are exchanged as commodities, are prescribed and consumed. They invoke an analytical framework of the ‘Social Lives of Medicines’, proposing that as things, medicines have biographies (S.R. Whyte et al., 2002). The authors trace the careers of medicines, often antimicrobial, and provide useful context for the ways in which these substances travel beyond the enclave of professional control and are made common. In drawing together a range of anthropological works, through which they illustrate how people in different settings, roles and industries, employ these substances for various endeavours, this volume is compelling in arguing that medicines should be understood beyond their capacity to cure (or poison).
The charm of pharmaceuticals, as concrete entities with wider symbolic, economic and political value, is a useful lens through which to consider how antimicrobial resistance may arise as well as how it may be tackled, especially in relation to the drivers of antimicrobial use. We can look at the value of antimicrobials for different actors in order to gain insights into the status quo, important to consider if intervention is to be undertaken, both to design effective interventions and to anticipate potential consequences beyond impact on AMR.
Development without Institutions
Sarah Pinto explores the emergence of so-called ‘informal providers’ of medicine and biomedical care in rural India. These providers are neither ‘formal’ nor ‘informal’, she argues, but instead “operate on the boundaries of legitimacy” (340). These ‘informal providers’ often fill the gaps where legitimate public health institutions have been too weakened to operate, and are informally sanctioned by the state because their operations are not regulated or denounced. These informal providers, Pinto writes, are actually “neither ‘quacks’ nor legitimate doctors”, but typically lay people who have self-trained, or been partially trained via a development scheme. They can “invent roles for themselves as medical authorities and representatives of development” (337) by claiming the authority of development and medical institutions. These claims go uncontested by legitimate institutions, who are aware of their work filling the gaps in communities with severely limited access to good health care.
In policy and development debates about ‘informal providers’ and their clients, though, informal providers are often characterized as rogue actors, both ‘irrational’ and exploitative, and clients are portrayed as uneducated and easily fooled. On the other hand ‘formal’ institutions are understood as modern, cosmopolitan; decidedly rational actors and purveyors of legitimate biomedical knowledge. In this way, what Pinto explains, is that despite on the ground evidence to the otherwise, formal and informal get defined in opposition to each other. Informal providers are “those against whom the educated and rational self is defined” (2004:356). The danger here is that we fail to understand the reasons why informal providers are trusted in the everyday lives of those who seek health care in environments with limited formal options, and likewise the institutional reasons they are propped up by governments and development organisations.
Anthropological Perspectives on Structural Adjustment and Public Health
Thirty years since its first public use in 1980, the phrase structural adjustment remains obscure for many anthropologists and public health workers. However, structural adjustment programs (SAPs) are the practical tools used by international financial institutions (IFIs) such as the International Monetary Fund (IMF) and the World Bank to promote the market fundamentalism that constitutes the core of neoliberalism. A robust debate continues on the impact of SAPs on national economies and public health. But the stories that anthropologists tell from the field overwhelmingly speak to a new intensity of immiseration produced by adjustment programs that have undermined public sector services for the poor. This review provides a brief history of structural adjustment, and then presents anthropological analyses of adjustment and public health. The first section reviews studies of health services and the second section examines literature that assesses broader social determinants of health influenced by adjustment.
