Key messages

Antibiotics are used to treat a variety of bacterial infections and to prevent wound infections following hip replacements, caesarean sections and other surgical procedures.

Antibacterial resistance (ABR) is increasing and by 2050, may lead to as many deaths as cancer.

Drivers of ABR include antibiotic use and ABR transmission – these are not purely biomedical or technical issues but can also be attributed to socio-cultural rationalities, policies and practices.

Understanding the cultural dimensions of antibiotic use and ABR transmission is a critical part of tackling the ABR challenge.

The issue

Antibiotics have played a hugely significant role in decreasing mortality rates and increasing life expectancy over the course of the 20^th century.  But the salvational qualities of antibiotics are quickly becoming undone. Antibacterial resistance – the process through which bacteria learn to resist the effects of naturally occurring and synthesised antibiotics – is increasing at an unprecedented rate. It is predicted that by 2025 many first line antibiotics will be ineffective.  By 2050, ABR may cause as many deaths as cancer. It is estimated that, without effective antibiotics, the rate of postoperative infections amongst patients undergoing hip replacements may be as high as 50%.

Predominating approaches to tackling the challenge of ABR have adopted a largely technical approach.  They have focused on key criteria including information campaigns, surveillance, rational use and technological innovation.  This approach, however, has tended to under appreciate the full complexity of the drivers of resistance.  In spite of the development of guidelines and recommendations, suboptimal practices of antibiotic use and consumption continue to be documented in a wide variety of contexts including in hospitals and in agricultural settings across the world.

Cultural contexts

Informational and educational ABR interventions have exerted little effect because predominating approaches to tackling ABR often forget that antibiotics are not simply or solely used for biomedical reasons. There are a diverse range of socio-cultural rationalities and practices which drive antibiotic use, consumption and ABR transmission. These include (but are by no means limited to) the desire to delimit patient-doctor confrontation in the GP clinic by issuing an antibiotic prescription; the desire to protect profit margins in challenging agricultural environments; and the desire amongst junior doctors in hospitals to conform to social ideals of good ‘independent’ doctoring by relying on broad spectrum antibacterials rather than consulting with senior staff.

These socio-cultural rationalities and practices compete with, co-exist alongside and diffract biomedical knowledge and information.  They exert different pressures in different parts of the world.

Instead of presuming that we live in a world where key actors lack knowledge, a cultural contexts of health (CCH) approach starts out from the presumption that we live in a full world. A full world is a world that is composed of multiple (and sometimes conflicting) socio-cultural sensibilities and multiple (e.g. antibiotic) practices.

Policy implications

Re-casting ABR as a social and cultural as well as a biological issue opens up a more expansive terrain for intervention and policy action.  Instead, for example, of calling for a ‘reduction’ in the use of antibiotics, or issuing doctors with further guidelines, a CCH approach might facilitate the development of training mechanisms which empower GPs to engage in challenging conversations with their patients.

Adopting a CCH approach requires social and political as well as biological innovation. Collaborative and participatory research methodologies are a critical component in helping to render tractable the knowledgeabilities and pressures faced by key actors including GPs, patients, farmers, regulators and biotechnology companies.

A CCH approach requires reconfiguring who is understood as an ‘expert’ and moving away from a policy culture which prioritises the dissemination of scientific information. It is only by taking socio-cultural dynamics seriously that we will be able to sustain effective and affirmative change on the scale required to tackle the growing challenge of ABR.

Links for further reading

1. Smith, R. (2013) ‘Antibiotic resistance “has the potential to undermine modern health systems,” available at: http://www.bmj.com/press-releases/2013/03/11/antibiotic-resistance-%E2%80%9Chas-potential-undermine-modern-health-systems%E2%80%9D; accessed 22/11/2017.
2. Stivers, T. (2007) Prescribing under Pressure: Parent-Physician Conversations and Antibiotics. Oxford University Press.
3. Charani, E., Castro-Sanchez, E., Sevdalis, N., Kyratsis, Y., Dumright, L., Shah, N and Holmes, A. (2013) ‘Understanding the Determinants of Antimicrobial Prescribing Within Hospitals: The Role of “Prescribing Etiquette”,’ Clinical Infectious Diseases, 57(2), pp. 188-196.
4. Broom, A., Broom, J., Kirby, E and Adams, J. (2016) ‘The social dynamics of antibiotic use in an Australian hospital,’ Journal of Sociology, 52(4), pp. 824-839).
5. Bingham, N. (2008) ‘Slowing things down: lessons from the GM controversy’, Geoforum, 39(1), pp. 111-112.