So broadening this discussion out, what is the social life of antibiotics? Well, the social life of antibiotics, in this context, is what social relations, whether they’re meta, whether they’re micro, shape what happens to them. So for example– and I’m going to go through some of these in the context of health– everything from the rituals of medicine, the problem of not knowing, of ignorance, of using antimicrobials as ultimately a means to be safe, from an individual’s perspective, benevolence, caring for a person and seeing the use of these drugs as an act of benevolence, as a matter of manners or even consumerism, and, probably most challengingly, political will, or as an economic artefact of the way we choose to live.
So I’m going to unpack the social life of antibiotics and those that use them and those that need them to actually explore what is happening, why, and how we might actually change that. Underpinning all of what I’m going to say in the forthcoming points is a key fallacy that drives the whole sector of attempts to address antimicrobial resistance. And that is the fallacy of behaviour change. Now, for a social scientist, we know that an individual’s behaviour is structured by the whole range of forces that essentially put them in the position they’re in. So behaviour is a product of context. This has not been accommodated in the context of antimicrobial stewardship, of the response to antimicrobial resistance.
What we still do, or what a lot of people or a lot of systems do, is they construct antimicrobial misuse as about bad behaviour, rather than as about systems or as about social relationships. What I want to do as a social scientist, and what we have been doing over the last nearly decade, is saying, antimicrobial resistance and the solutions therein are actually embedded in the cultural fabric of modern societies and the way we’re organised economically, socially, and politically. Antimicrobial resistance is essentially the outcome or the problem of values and culture, rather than individual behaviour. So let’s move beyond individual behaviour and think about, OK, what does actually drive what people do, how people act?
And how might we change as a result? Antimicrobial stewardship has been a central platform for addressing antimicrobial resistance. Optimise, be judicious in how you utilise our remaining antimicrobials. AMS programmes, or antimicrobial stewardship programmes, aim to help clinicians and organisations optimise the treatment of infections and reduce adverse events associated with antibiotics– so in theory, a very positive move. Stewardship, unfortunately, in how it’s been implemented, nationally and internationally, has tended towards what social scientists would say is the valorisation of the individual. The very logics that I was talking about before– the idea that a person behaves in particular ways and, therefore, they are responsible– have permeated the antimicrobial stewardship agenda.
What we essentially have is a model of stewardship in our institutions that are about surveillance, restriction, and correction. That is all about identifying people, identifying problems or bad decisions, and correcting those. And there lies a major problem in this field– the idea that identifying and correcting individual actions might actually solve this problem. Yet, it absolutely does not address the sociological dimensions of why we are here in the first place– the structural dynamics of what is occurring.
This idea of stewardship, or this vision of stewardship, is somewhat of a hangover, if you like, from this kind of rational therapeutics model that gained traction post-1950s– the idea that we can sort of just say, here’s what you should do - change - and that these actors would somehow go, oh, OK, that’s what we’re supposed to do. And therefore, we’ll act differently. We know, as social scientists, that, in fact, this is not how people change. It is actually understanding or recognition of why they act the way they do and developing support processes accordingly that promotes change. What I’m essentially arguing is that we need to reframe the problem.
Surveillance, restriction, and correction models of antimicrobial stewardship neglect a whole range of societal considerations. And the focus on individual behaviour change is deeply rooted in ideology. It denies the why of how we act, the structural limitations of what we’re able to do. It constructs us as actors when, in fact, we can’t necessarily act any other way. So what we can do is use a sociological perspective to say, OK, why do people continue to so-call act irrationally? And how might we actually address those institutionally, rather than just tell people what to do or how to behave differently? Another key issue in antimicrobial resistance, but also attempts to optimise, is the fact that institutions vary considerably over place, over locale.
What we have, often, is a set of core institutions, often in metropolitan centres, major cities, who say, this is what we need to do. And what you then get is peripheral or marginal locations who actually aren’t resourced in the same ways, who aren’t experiencing, say, antimicrobial resistance as a core issue, who are experiencing other priorities, and who aren’t necessarily going to take that well to being told, here’s a national framework. This is what you need to do, and this is how you need to do it. So from a social science perspective, it’s really important to think about core periphery relations in the context of antimicrobial resistance and in the context of antimicrobial stewardship.
So given that, we, as part of this large study that we completed, went to a remote hospital. And we did interviews with clinicians there to talk to them about, what do you think of antimicrobial resistance? And what do you think about antimicrobial stewardship? Here’s a response that one person gave me in an interview whilst doing fieldwork. I’ve worked in pools of pus. I’ve learned how to give antibiotics robustly. But the antimicrobial people, they’ll come along, and they’ll have a heart attack, won’t they? They’re wrong. I’m getting attacked continually. We’ll get to see our adverse outcomes from not treating with antibiotics. To start nit-picking about the number of antibiotics, the dose of antibiotics, is just simply folly.
I don’t see how we can just say, as a profession, we’re going to follow some trendy concept, and the resulting patient deaths are OK. Now, I view this quote and the many other stories that I got, spending time in this remote hospital, as evidence of the importance of understanding people’s contexts, what they’re facing, the challenges that they have managing external expectations versus local constraints.
Highly vulnerable populations: they’re working with essentially very limited resources. And yet, we come in saying, you need to wind back your antimicrobials. You need to do this, and you need to do that. And that simply will not work. We heard this story over and over again. And one of our take-home messages here, in terms of how to respond to antimicrobial resistance, is that if you don’t understand and encompass people’s context, you will never get them to change. I want to sum up this talk on the social life of antibiotics by reiterating the core point.
Use of antimicrobials is governed by a range of social factors, ranging from political will, ignorance, ritual, benevolence, manners, deference, fear, consumerism– which I haven’t touched on here but is an incredibly important dynamic– and risk. If we don’t look at antimicrobial resistance as a sociological problem, we will be entrenched in these social practises, but yet considering them to be a rational medical act. And that is a major costly and global problem. To conclude, social dynamics have a major influence on our capacity to enact antimicrobial stewardship and to even decelerate antimicrobial resistance. The social remains our best chance of protecting the existing drugs we have, but, most importantly, protecting any that we develop.
If we don’t change and address social dynamics, we will have the same problems, no matter how many drugs we develop in the future. Interventions that just count, that give us data about ‘what’ but don’t give us any data about ‘why’, will be costly and ultimately construct those often most vulnerable as hot spots of bad prescribing or overuse, taking in no account of why that might be the case. Take-home message from a social science perspective– if you don’t document why, you won’t be able to promote change. I’m Alex Broom, Professor of Sociology from the University of Sydney, and thanks for listening to the social life of antibiotics.