Antibiotics have played a significant yet ambivalent role in Western livestock husbandry. Mass introduced to agriculture to boost animal production and reduce feed consumption in the early 1950s, agricultural antibiotics were soon accused of selecting for bacterial resistance, causing residues and enabling bad animal welfare. The dilemma posed by agricultural antibiotic regulation persists to this day. This essay traces the history of British antibiotic regulation from 1953 to the influential 1969 Swann report. It highlights the role that individual experts using bacteriophage typing played in warning about the mass selection for bacterial resistance on farms and the response of a corporatist system, whose traditional laissez-faire arrangements struggled to cope with the risk posed by bacterial resistance. In addition to contextualizing the Swann report’s origins, the essay also discusses the report’s fate and implications for current antibiotic regulation.
Format: Journal
Toxic confusion
In November 2014, the German weekly Die Zeit confronted readers with a disturbing image. Staring at each other across the title page were a friendly looking pig and a human wearing a surgeon’s mask. The image was titled ‘‘Revenge From the Sty.’’1 Inside the issue, numerous articles warned about the overuse of antibiotics on German farms and the dire health effects of resistant pathogens. The November issue of Zeit marked the beginning of a series of Zeit reports dedicated to bacterial resistance and hygiene problems in food production and hospitals. According to Correct!v, the reporter collective behind many of the articles, the three most common multi-resistant pathogens (MRSA, ESBL, and VRE) were annually responsible for over 30,000 deaths and at least 1,000,000 infections in German hospitals. However, resistant bacteria were not limited to hospitals. Since the early 2000s, multi-resistant LA-MRSA CC398 had spread rapidly throughout German sties. In the intensive animal husbandry regions of Northern Germany, almost every third detected colonisationof humans with MRSA was defined as ‘‘livestock-associated’’ and almost 10% of infections detected in humans were caused by LA-MRSA CC398. Accordingly, the Zeit accused farmers and veterinarians of overusing antibiotics and endangering public health for the sake of cheap meat and quick profits.
Pharmacies, Self-Medication and Pharmaceutical Marketing in Bombay, India
This is a detailed ethnographic investigation into the social and economic realities of pharmacies in urban India, with a specific focus on Mumbai. Kamat and Nichter explain how pharmacies do not exist in a vacuum, but rather the practices of staffing, stocking antibiotics, and giving advice on antibiotic use are all highly influenced by the economic and social context of the retail medicine business. Most studies on pharmacies and pharmacists in the global south have focused on pharmacist and pharmacy attendant interactions with patients and how these interactions increase or decrease antibiotic use, self-medication and experimentation. What has been missing is the economic and social context of these interactions. Here, Kamat and Nichter explain how pharmacies are deeply entangled within local economic systems and global pharmaceutical economic systems and supply chains: Pharmacies are increasingly lucrative business ventures, and ‘setting up shop’ in under-regulated informal communities has become an easy way to avoid intensive start-up costs. But this abundance of pharmacies has led to competitive pricing between pharmacies, the use of ‘agents’ to lure people to their shops, and a model of ensuring client satisfaction to guarantee return customers, which includes ensuring clients have access to drugs without a prescription, discounts, and extending credit to clients in need.
On the other side, pharmacy owners are targeted by aggressive marketing strategies by pharmaceutical companies, who offer appealing incentive schemes, including rebates, ‘buy some get some free’ schemes, stock bonuses, gifts, and cash discounts. These economic systems extend beyond the pharmacy, the authors explain: “Medreps who represent pharmaceutical companies encourage doctors to prescribe their products and pharmacies to stock them. To accomplish the latter, medreps act as intermediaries assisting pharmacies to liquidate unsold and slow moving stocks. A complex chain of symbiotic relationships between all parties involved in medicine dispensing and sales influences pharmaceutical practice” (792, emphasis added).
This study suggests that more attention need to be paid to the social and economic context within which antibiotics are sold and used. Treating the encounter between pharmacist (or pharmacy attendant) and client as if in a vacuum will obscure important insights relevant antibiotic use and AMR policy.
“I thought it was ordinary fever!”
A major question concerning policy makers and public health specialists alike is why some mothers and caretakers delay in seeking medical treatment for children with a fever. This paper, based on ethnographic research in Tanzania, complicates recent work that has argued that the main cause for delayed treatment seeking in East Africa is the implementation of monetary fees on visits to health facilities. Economic considerations may deter and the use of public facilities, but this seems not to be the main cause of delayed treatment. Rather, care-seeking for childhood febrile illness is mediated by several social factors, including “cultural meanings [of fever], perceived severity and past experience, structural disadvantages affecting women’s access to societal resources, contingent circumstances, and, above all, the patterns of communication between patients/caretakers and health care providers in government health facilities” (2946).
Three key findings for delayed treatment are explained in detail: First, most mothers and caretakers said they delayed treatment because they ‘thought it was ordinary fever’ and not malaria. This belief was undergirded by previous experiences within clinics, where they typically received only ambiguous diagnoses. Indeed, as Kamat explains, “most of the encounters between the dispensary staff and mothers are characterized by patterns of communication that are vague and inconclusive” (2956), leading mothers to depend on knowledge about malarial symptoms gained through word of mouth and second-hand experiences within their social networks. Second, previous experience in constrained health systems greatly impacted decisions to seek treatment. Many mothers reported apprehension about availability of diagnostic testing, access to and efficacy of medications, and the time and labour involved in travelling long distances by foot to a potentially under-resourced facility. Third, these factors contributed to strategic symptom reporting, in order to garner more attention for their children in an environment of limited resources. Mothers, for example, often strategically avoided sponge-bathing their children to lower fever before attending a clinic because they worried that sponge-bathing would lower the fever to the point that their child would not be a major concern for clinicians. This suggests that mothers are not unknowledgeable about how to lower fevers, but rather make strategic decisions that reflect the reality of seeking treatment in severely constrained health care settings.
Bringing the state into the clinic?
The roles that rapid, point-of-care tests will play in healthcare in low-income settings are likely to expand over the coming years. Yet, very little is known about how they are incorporated into practice, and what it means to use and rely upon them. This paper focuses on the rapid diagnostic test for malaria (mRDT), examining its introduction into low-level public health facilities in Tanzania within an intervention to improve the targeting of costly malaria medication. We interviewed 26 health workers to explore how a participatory training programme, mobile phone messages, posters and leaflets shaped the use and interpretation of the test. Drawing on notions of biopolitics, this paper examines how technologies of the self and mechanisms of surveillance bolstered the role mRDT in clinical decision-making. It shows how the significance of the test interacted with local knowledge, the availability of other medication, and local understandings of good clinical practice. Our findings suggest that in a context in which care is reduced to the provision of medicines, strict adherence to mRDT results may be underpinned by increasing the use of other pharmaceuticals or may leave health workers with patients for whom they are unable to provide care.
Geographies of Folded Life
In this carefully thought out piece on biosecurity and the drive to create ‘biosecure’ and ‘disease-free’ pigs in the United Kingdom, Hinchliffe and Ward (2014) detail the ways that farmers actively work with, rather than against, complex microbial environments, in the ‘making of safe life’ for pigs and humans. The authors outline the kinds of situated knowledge and practices that vets, breeders and farmers deploy to raise healthy pigs, and how this in-depth knowledge is “obscured and even endangered when biosecurity is reduced to the simple protection of disease-free livestock”.
Raising and keeping healthy pigs – that are healthy for humans and the environments they live in – is a complex dance that is more than just ‘keeping disease out’. In fact, the relations and interactions of animals, microbes and people are key to ensuring health. When policy tries to reduce these complex relations into universal categories called ‘disease-free’ or ‘biosecure’ it risks being part of the problem, not the solution. How might we instead enable and listen to farmers about how they manage complex and heterogeneous disease immunity in their pigs that actually allows them to manage threats to health? As Hinchliffe and Ward write, “practitioners are not responsible for biosecurity, but responsive to living complexities and make valuable contributions towards making life safe.”
More than one world, more than one health
The One World One Health (OWOH) has emerged in response to the growing recognition that human, animal, and environmental health are knotted together, and that each cannot be approached as if in a silo. How does this work in practice, however, with competing demands and concerns of various agencies, actual livelihoods, and differential access to treatment and knowledge? Hinchliffe uses the Avian Influenza as an example to work through the competing demands of agencies charged with halting the spread of disease, but also to demonstrate what is missing from an OWOH approach overall, namely a recognition of how diseases are ‘configured’ (Rosenberg 1992) by socio-economic and material vulnerabilities. In short, the spread of disease almost always traces pathways of vulnerability.
How a disease spreads is acutely tied to uneven access to social and political resources, unequal exposure to environmental risk, and the ways that livelihoods impact the kinds of decisions people can make, such as culling chickens amid an avian influenza crisis. This ‘configuration’ of disease is almost always neglected. Instead disease and ‘outbreaks’ are often framed as a problem of contamination and transmission. As Hinchliffe writes, “once disease is framed as predominantly a matter of contamination…we risk missing all manner of key issues for animal and public health. The point to carry forward is that a One World approach….may miss the vital importance of social conditions and downplay the role of context or, more epidemiologically speaking, the intricate relations between host, pathogens and environment (which includes of course the complex of cultural and social relations) in contributing to disease” (30). Taking interspecies health seriously, then, requires us to attend to a diverse range of activities that are tied to health, to actively cultivate an approach to zoonotic disease that is transdisciplinary, and to contend with the complex practices, things and relations that make-up both health and disease.
Works Cited:
Rosenberg, C.E. 1992. Explaining Epidemics: And Other Studies in the History of Medicine. Cambridge: Cambridge University Press.
The goat that died for family
Animal sacrifice can be productively theorized as a practice of kindred intimacy between human and nonhuman animal. Drawing on ethnographic fieldwork in India’s Central Himalayas, I trace how the ritual sacrifice of goats in the region’s mountain villages acquires power and meaning through its anchoring in a realm of interspecies kinship. This kinship between humans and animals is created and sustained through everyday practices of intercorporeal engagement and care. I contend, in fact, that animal sacrifice is itself constitutive of interspecies kin relations. The spectacular act of violence at the heart of sacrifice—the beheading of the sacrificial animal—is crucial to the constitution of kin solidarity between human sacrificer and animal victim. From this perspective, animal sacrifice creates a world rich with the possibility of mutual response and recognition between different beings entangled in intimate and complex ways.
The Politics of Reproduction
The topic of human reproduction encompasses events throughout the human and especially female life-cycle as well as ideas and practices surrounding fertility, birth, and child care. Most of the scholarship on the subject, up through the 1960s, was based on cross-cultural surveys focused on the beliefs, norms, and values surrounding reproductive behaviors. Multiple methodologies and subspecialties, and fields like social history, human biology, and demography were utilized for the analysis. The concept of the politics of reproduction synthesizes local and global perspectives. The themes investigated include: the concept of reproduction, population control, and the internationalization of state and market interests (new reproductive technologies); social movements and contested domains; medicalization and its discontents; fertility and its control; adolescence and teen pregnancy; birth; birth attendants; the construction of infancy and the politics of child survival; rethinking the demographic transition; networks of nurturance; and meanings of menopause. The medicalization of reproduction is a central issue of studies of birth, midwifery, infertility, and reproductive technologies. Scholars have also analyzed different parts of the female life-cycle as medical problems. Other issues worth analysis include the internationalization of adoption and child care workers; the crisis of infertility of low-income and minority women who are not candidates for expensive reproductive technologies; the concerns of women at high risk for HIV whose cultural status depends on their fertility; questions of reproduction concerning, lesbians and gay men (artificial insemination and discrimination in child rearing); the study of menopause; and fatherhood. New discourse analysis is used to analyze state eugenic policies; conflicts over Western neocolonial influences in which women’s status as childbearers represent nationalist interests; fundamentalist attacks on abortion rights; and the AIDS crisis.
Science as Culture, Cultures of Science
Although controversial, science studies has emerged in the 1990s as a significant culture area within anthropology. Various histories inform the cultural analysis of science, both outside and within anthropology. A shift from the study of gender to the study of science, the influence of postcolonial critiques of the discipline, and the impact of cultural studies are discussed in terms of their influence upon the cultural analysis of science. New ethnographic methods, the question of “ethnosciences” and multiculturalism, and the implosion of informatics and biomedicine all comprise fields of recent scholarship in the anthropology of science. Debates over modernism and postmodernism, globalization and environment, and the status of the natural inform many of these discussions. The work of Escobar, Hess, Haraway, Martin, Rabinow, Rapp, and Strathern are used to highlight new directions within anthropology concerning both cultures of science and science as culture.
