Microbes, Science and Society

We face a post-antibiotic future.  To manage infectious disease, we will need new ways of thinking about living with microbes – ones that draw on knowledge across biological research, clinical care and lay health practices.

This blog is dedicated to the memory of Catherine Will, one of the founding Editors of the Cost of Living, whose research has been a huge influence on how we think about the role of sociology in relation to biomedicine.

The antibiotic age has been brief. In the early 1990s, older GPs I interviewed recalled qualifying before antibiotics were in routine use in the UK; in 1951, a young doctor in Argentina could write to his mother of “a dose of a little-known drug, penicillin”.   Barely a human lifetime later, with growing antimicrobial resistance (AMR) and the slowing pace of development of new antibiotics, we can no longer rely on antibiotics to treat bacterial infections.

Early optimism that antibiotics heralded the end of infectious disease was always tempered with anxiety about over-use. Yet for decades triumphalist talk about ‘magic bullets’ suffused both scientific and lay discourse.  As Charlotte Humphrey noted, even Ivan Illich, in his polemic text Medical Nemesis, exempted antibiotics from his general critique of medical hubris. Today, rather than representing an exception, antibiotics are an exemplary symbol of biomedicine’s limits. Once miraculous, they now reveal the downsides of a medical model rooted in human exceptionalism, technological fixes, and war-like explanatory models and metaphors.

The growing dominance of pharmaceutical solutions over the second half of the twentieth century meant that, in much of the world, antibiotics rapidly became the first port of call for bacterial infections. They were not, though, the only available therapy. One alternative was phage therapy – the administration of bacteriophages, viruses that kill bacteria without damaging their hosts. Phages are carefully selected for specific bacteria, as they can only replicate in those bacteria: they therefore have fewer effects on the wider patient microbiome than antibiotics.  However, as antibiotics became readily available, as Charlotte Brives and Jessica Pourraz document, “phage therapy plunged into almost total oblivion”.  In the UK, and much of the world, it is now solely a treatment of ‘last resort’, when antibiotic alternatives have failed. Providing phage therapy typically entails considerable (sometimes insurmountable) administrative challenges for clinicians, as it is neither regulated nor approved.  Brives and Pourraz suggest these challenges arise from the ‘disruptive’ nature of phages for biomedicine. They do not fit the dominant models of disease control that arose in the antibiotic era.  Unlike antibiotics, phages are biological, living, evolving organisms and are hard to standardise and test in a randomised controlled trial, as they are selected for the specific patient and their infection.  Without trial evidence of safety and efficacy, regulatory agencies cannot approve them.  Phages are abundant in the natural environment, so they are also hard to extract profit from unless genetically modified, a virus cannot be patented.

In some countries, however, phage therapy did not fade into oblivion. In Russia and Eastern Europe, where access to antibiotics was more limited, phage therapy continued to develop.  Tbilisi, Georgia, has an international research centre, and phage therapy is well established in countries such as Poland, where evidence of safety and effect, built on case studies, pre-dates contemporary requirements for clinical trials.

A recent study by Susan Banducci, Vicki Gold and colleagues, of public views on the acceptability of phage therapy, found that this history affected public willingness to trust and use phages. In an experiment, UK respondents who were told that the therapy was approved for use in Georgia were significantly less likely to trust it than those told it was used in Belgium.  Using words such as ‘kill’ and ‘virus’ to describe the mechanism of bacteriophages also reduced likelihood of accepting treatment. The team also found patient acceptability was key to whether clinicians would consider phage therapy.

Developing alternatives to antibiotics such as phage therapy, then, will require both more plural approach to evidence and new coalitions between researchers, publics and clinicians.  Alternatives do not gain traction just because they might work: they need a story that makes sense to patients, and to clinical professionals.

Phages are unlikely to replace antibiotics as a new ‘magic bullet’. They are, however, one promising component of a post-antibiotic future.  Publics are as crucial as laboratory science and clinical expertise to this future.  What Catherine Will and Kate Wiener framed as ‘DIY’ health practices – the complex combinations of medical and other technologies and practices brought together to manage everyday health – are a vital source of knowledge about how humans can live with microbes.  Pro-biotics, eating fermented foods to promote gut health, avoiding antimicrobial cleaning products, even acquiring hookworm infection to reduce the symptoms of coeliac disease, are all examples of DIY approaches that seek to reset relations with the multiple species that make up and surround the human body.  These practices are not separate from biomedicine: physicians become enrolled if patients request phage therapy; patient activist groups might organise to press for trials; and scientists might enrol the public as citizen scientists to help find phages.

Public knowledge is important. Yet all too often, particularly with regard to challenges such as AMR, it is conceptualised as merely ‘belief’ that feeds into problematic behaviours such as failing to use antibiotics correctly, or demanding inappropriate prescriptions, rather than a source of productive engagement. Catherine Will’s research has been influential in moving beyond this behavioural frame, and building in care around what people do, rather than just what they think, and respecting publics as reflective citizens.

The ‘more-than-human’ turn, informed by both new biological understandings of the microbiome and ‘DIY’ health practices, is shaping contemporary clinical and public health.  This has the potential to open up biomedicine to much-needed new ways of thinking about health and care. It is not, however, inevitable that it does so. As Roberta Pala and Katherine Kenny found, drawing on health promotion information for Australian mothers, if the focus remains on individualised responsibilities for health, folding in the microbiome can merely increase the burden for mothers, as one more health risk to manage for their children. Instead, they suggest, we could refocus on the “ecological and cooperative implications of human-microbial relations”.

Our post-antibiotic age will need new metaphors such as this to reset biomedicine for a less hubristic, more plural future.  The martial metaphors that still dominate – we battle cancer,  wage war on drugs, and build our resilience to fight infections – are no longer appropriate with a new understanding of the complexities of the microbiome.  This reset might fruitfully also apply to our models of science, medicine and society. Locating medical expertise and lay understanding on either side of a divide is unhelpful, with innovations arising from everyday practices as well as the laboratory.  We will need greater sensitivity to the coalitions that can be built around learning to live with microbial species, and, as Catherine Will advocated, an appreciation of difference and doubt in the effects of biomedicine.