History Teaches Us That Confronting Antibiotic Resistance Requires Stronger Global Collective Action

Antibiotic development and usage, and antibiotic resistance in particular, are today considered global concerns, simultaneously mandating local and global perspectives and actions. Yet such global considerations have not always been part of antibiotic policy formation, and those who attempt to formulate a globally coordinated response to antibiotic resistance will need to confront a history of heterogeneous, often uncoordinated, and at times conflicting reform efforts, whose legacies remain apparent today. Historical analysis permits us to highlight such entrenched trends and processes, helping to frame contemporary efforts to improve access, conservation and innovation.

Global Pharmaceuticals

In some parts of the world spending on pharmaceuticals is astronomical. In others people do not have access to basic or life-saving drugs. Individuals struggle to afford medications; whole populations are neglected, considered too poor to constitute profitable markets for the development and distribution of necessary drugs. The ethnographies brought together in this timely collection analyze both the dynamics of the burgeoning international pharmaceutical trade and the global inequalities that emerge from and are reinforced by market-driven medicine. They demonstrate that questions about who will be treated and who will not filter through every phase of pharmaceutical production, from preclinical research to human testing, marketing, distribution, prescription, and consumption.

Whether considering how American drug companies seek to create a market for antidepressants in Japan, how Brazil has created a model HIV/AIDS prevention and treatment program, or how the urban poor in Delhi understand and access healthcare, these essays illuminate the roles of corporations, governments, NGOs, and individuals in relation to global pharmaceuticals. Some essays show how individual and communal identities are affected by the marketing and availability of medications. Among these are an exploration of how the pharmaceutical industry shapes popular and expert understandings of mental illness in North America and Great Britain. There is also an examination of the agonizing choices facing Ugandan families trying to finance AIDS treatment. Several essays explore the inner workings of the emerging international pharmaceutical regime. One looks at the expanding quest for clinical research subjects; another at the entwining of science and business interests in the Argentine market for psychotropic medications. By bringing the moral calculations involved in the production and distribution of pharmaceuticals into stark relief, this collection charts urgent new territory for social scientific research.

On the monopoly

The drug patent monopoly has been described as a key deterrent to Africans’ access to brand-name, life-saving drugs. Research in Nigeria, however, shows that another factor restricts access in that country: Brand-name pharmaceutical companies’ pricing and marketing strategies keep patented drugs off the market. In this article, I retheorize the question of monopoly in the pharmaceuticals industry. I first track the historical precedents of this particular iteration of the drug monopoly. I then situate the monopoly in the context of ethnographic research I conducted on pharmaceutical markets and drug marketing (2005–10) as well as on Nigeria’s compliance struggles with the WTO’s Trade Related Aspects of Intellectual Property (TRIPs) Agreement (1999–2003). TRIPs enforces patent holders’ rights and mandates intellectual property harmonization across nation-states. In analyzing these two ethnographic sites together, I argue that rather than its purported short-term legal existence, the current drug monopoly operates as though it has an indefinite life.

What Can Critical Medical Anthropology Contribute to Global Health?

We are now facing an unprecedented moment in the history of global health, in which infectious diseases such as HIV/AIDS, malaria, and tuberculosis are no longer peripheral concerns but primary targets of bilateral aid programs, philanthropy, and research. The Critical Anthropology of Global Health Special Interest Group of the Society for Medical Anthropology is committed to bringing a critical perspective to global health that encompasses factors that contribute to the maldistribution of disease, health care inequities, and problems in health care management, within a biopolitical environment.

Post-Pasteurian Cultures

Out of concern for public health, the U.S. government bans the sale of cheese made from unpasteurized milk if it is aged fewer than 60 days. But while the FDA views raw-milk cheese as a potential biohazard, riddled with pathogenic microbes, aficionados see it as the reverse: as a traditional food processed for safety by the action of good microbes. This article offers a theoretical frame for understanding the recent rise in American artisan raw-milk cheese production, as well as wider debates over food localism, nutrition, and safety. Drawing on ethnographic interviews with cheese makers and purveyors and on participant-labor conducted on a Vermont sheep dairy farm, I develop the concept of microbiopolitics to analyze how farmer–cheese makers, industry consultants, retailers, and consumers negotiate Pasteurian (hygienic) and post-Pasteurian (probiotic) attitudes about the microbial agents at the heart of raw-milk cheese and controversies about this nature–culture hybrid.

Thick Prescriptions

Anthropologists of medicine and science are increasingly studying all aspects of pharmaceutical industry practices–from research and development to the marketing of prescription drugs. This article ethnographically explores one particular stage in the life cycle of pharmaceuticals: sales and marketing. Drawing on a range of sources-investigative journalism, medical ethics, and autoethnography–the author examines the day-to-day activities of pharmaceutical salespersons, or drug reps, during the 1990s. He describes in detail the pharmaceutical gift cycle, a three-way exchange network between doctors, salespersons, and patients and how this process of exchange is currently in a state of involution. This gift economy exists to generate prescriptions (scripts) and can mask and/or perpetuate risks and side effects for patients. With implications of pharmaceutical industry practices impacting everything from the personal-psychological to the global political economy, medical anthropologists can play a lead role in the emerging scholarly discourse concerned with critical pharmaceutical studies.

Risk, Vulnerability, and Harm Reduction

Based on long-term ethnographic research, Nichter explores how and why the use of antibiotics as prophylaxis has emerged as the main way that sex workers and their clients believe they can protect themselves from Sexually Transmitted Infections (STIs). Nichter’s research provides some excellent insights into the often noted disjuncture between behaviour and knowledge, arguing that while sex workers and their clients are indeed knowledgeable about STIs, they still make decisions that most public health practitioners would deem forms of ‘risky behaviour’.

In order to understand this, Nichter asks us to pay more attention to “popular interpretations of risk messages, personal perceptions of vulnerability, and practices adopted to reduce risk or decrease harm from STIs which lie outside the purview of public health guidelines (and wisdom)” (102). While public health practitioners often assume that more knowledge about risk will prevent risk, Nichter details how risk is deeply subjective and always understood in context, and therefore it is never just about ‘more’ knowledge, but knowledge that matters to people in their everyday lives. In this way, if we take a universal ‘rational-man’ approach to public health messaging, we miss the ways people situate and make sense of risk and risky behaviours in relation to their own personal circumstances, social and political relations, and notion of self-identity.

“The post-antibiotic apocalypse” and the “war on superbugs”

Discourses evoking an antibiotic apocalypse and a war on superbugs are emerging just at a time when so-called “catastrophe discourses” are undergoing critical and reflexive scrutiny in the context of global warming and climate change. This article combines insights from social science research into climate change discourses with applied metaphor research based on recent advances in cognitive linguistics, especially with relation to “discourse metaphors.” It traces the emergence of a new apocalyptic discourse in microbiology and health care, examines its rhetorical and political function and discusses its advantages and disadvantages. It contains a reply by the author of the central discourse metaphor, “the post-antibiotic apocalypse,” examined in the article.

Rethinking Informality

If informality has been conventionally understood as a territorial formation or as a labour categorisation, this paper offers an alternative conceptualisation that conceives informality and formality as forms of practice. The paper examines how different relations of informal and formal practice enable urban planning, development and politics, and explores the changing relationship between informality and formality over time. To illustrate the political potential of conceiving informality and formality as practices, it highlights the fall-out from a particular urban crisis: the 2005 Mumbai monsoon floods. In the final section, the paper offers three conceptual frames for charting the changing relations of informal and formal practices: speculation, composition, and bricolage.

The politics of care in technoscience

In this special issue of Social Studies of Science, each contributor approaches the topic of care within technoscience with a lens that privileges the power relations that entangle humans and more-than-human others, carefully articulating “a feminist politics of care” (626). These articles each grapple with ‘darker’ sides of care: “The essays in this Special Issue speak to this complexity, showing how acts of care are always embroiled in complex politics. Care is a selective mode of attention: it circumscribes and cherishes some things, lives, or phenomena as its objects. In the process, it excludes others. Practices of care are always shot through with asymmetrical power relations: who has the power to care? Who has the power to define what counts as care and how it should be administered? Care can render a receiver powerless or otherwise limit their power. It can set up conditions of indebtedness or obligation. It can also sediment these asymmetries by putting recipients in situations where they cannot reciprocate. Care organizes, classifies, and disciplines bodies. Colonial regimes show us precisely how care can become a means of governance. It is in this sense that care makes palpable how justice for some can easily become injustice for others…How then do we grapple with and ‘unsettle’ easy assumptions about care” (627).

Each of these articles in this Special Issue consider this final question.

Caring for nanotechnology? Being an integrated social scientist, by Ana Viseu

One of the most significant shifts in science policy of the past three decades is a concern with extending scientific practice to include a role for ‘society’. Recently, this has led to legislative calls for the integration of the social sciences and humanities in publicly funded research and development initiatives. In nanotechnology – integration’s primary field site – this policy has institutionalized the practice of hiring social scientists in technical facilities. Increasingly mainstream, the workings and results of this integration mechanism remain understudied. In this article, I build upon my three-year experience as the in-house social scientist at the Cornell NanoScale Facility and the United States’ National Nanotechnology Infrastructure Network to engage empirically and conceptually with this mode of governance in nanotechnology. From the vantage point of the integrated social scientist, I argue that in its current enactment, integration emerges as a particular kind of care work, with social scientists being fashioned as the main caretakers. Examining integration as a type of care practice and as a ‘matter of care’ allows me to highlight the often invisible, existential, epistemic, and affective costs of care as governance. Illuminating a framework where social scientists are called upon to observe but not disturb, to reify boundaries rather than blur them, this article serves as a word of caution against integration as a novel mode of governance that seemingly privileges situatedness, care, and entanglement, moving us toward an analytically skeptical (but not dismissive) perspective on integration.

Abyssal intimacies and temporalities of care: How (not) to care about deformed leaf bugs in the aftermath of Chernobyl, by Astrid Schrader

Prompted by a classroom discussion on knowledge politics in the aftermath of the Chernobyl disaster, this article offers a reading of Hugh Raffles’ Insectopedia entry on Chernobyl. In that entry, Raffles describes how Swiss science-artist and environmental activist Cornelia Hesse-Honegger collects, studies, and paints morphologically deformed leaf bugs that she finds in the proximity of nuclear power plants. In exploring how to begin to care about beings, such as leaf bugs, this article proposes a notion of care that combines an intimate knowledge practice with an ethical relationship to more-than-human others. Jacques Derrida’s notion of ‘abyssal intimacy’ is central to such a combination. Hesse-Honegger’s research practices enact and her paintings depict an ‘abyssal intimacy’ that deconstructs the oppositions between concerns about human suffering and compassion for seemingly irrelevant insects and between knowledge politics and ethics. At the heart of such a careful knowledge production is a fundamental passivity, based on a shared vulnerability. An abyssal intimacy is not something we ought to recognize; rather, it issues from particular practices of care that do not identify their subjects of care in advance. Caring or becoming affected thus entails the dissociation of affection not only from the humanist subject, but also from movements in time: from direct helping action and from the assumption that advocacy necessarily means speaking for an other, usually assumed to be inferior.

Making time for soil: Technoscientific futurity and the pace of care, by Maria Puig de la Bellacasa

The dominant drive for understanding soil has been to pace its fertility with human demand. Today, warnings about soil’s exhaustion and endangered ecology raise concerns marked by fears of gloomy environmental futures, prompting scientists and soil practitioners urgently to develop better ways of taking care of soils. Yet the pace required by ecological soil care could be at odds with the predominant temporal orientation of technoscientific intervention, which is driven by an inherently progressivist, productionist and restless mode of futurity. Through a conceptual and historical approach to the soil sciences and other domains of soil knowledge, this article looks for soil ontologies and relations to soil care that are obscured by the predominant timescape. Contemporary discussions of the future of the soil sciences expose tensions between ‘progress as usual’ – by intensifying productivity – and the need to protect the pace of soil renewal. The intimate relation of soil science with productionism is being interrogated, as ecology attempts to engage with soil as a living community rather than a receptacle for crops. In this context, and beyond science, the ‘foodweb’ model of soil ecology has become a figure of alternative human–soil relations that involve environmental practitioners in the soil community. Reading these ways of making time for soil as a form of ‘care time’ helps to reveal a diversity of more-than-human interdependent temporalities, disrupting the anthropocentric appeal of predominant timescales of technoscientific futurity and their reductive notion of innovation.

Unsettling care: Troubling transnational itineraries of care in feminist health practices, by Michelle Murphy

Responding to the call by Maria Puig de la Bellacasa for Science and Technology Studies to take up ‘matters of care’, this article cautions against equating care with positive feelings and, in contrast, argues for the importance of grappling with the non-innocent histories in which the politics of care already circulates, particularly in transnational couplings of feminism and health. The article highlights these histories by tracing multiple versions of the politics of care in a select set of feminist engagements with the pap smear and cervical cancer. Drawing on postcolonial and indigenous feminist commitments, as well as amplifying Donna Haraway’s call to ‘stay with the trouble’, the article seeks to disturb hegemonic histories and arrangements of race, colonialism, and political economy, while simultaneously valuing divergent multi-local itineraries as relevant to technoscientific matters of care. This call for a politics of ‘unsettling’ care strives to stir up and put into motion what is sedimented, while embracing the generativity of discomfort, critique, and non-innocence.

Care in context: Becoming an STS researcher, by Melissa Atkinson-Graham, Martha Kenney, Kelly Ladd, Cameron Michael Murray, Emily Astra-Jean Simmonds

This collaborative article, written by graduate students who attended the Politics of Care in Technoscience Workshop, brings the themes in this volume to bear on their own developing science and technology study projects and research practices. Exploring the contours of five specific moments where questions of care have arisen in the course of their everyday research, they do not find a single or untroubled definition of care; instead, care is often a site of ambivalence, tension, and puzzlement. However, despite this uneasiness, they argue that taking the time to reflect on the multiple, sometimes conflicting, forms and definitions of care within a specific research context can inform the way that science and technology studies scholars envision and conduct their work.

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