Microbial semiotics: Sites of ideological work in antibiotic resistance

Abstract

As I was wrapping up fieldwork in Guatemala in late 2021, I encountered and saved an advertisement circulating on Instagram (Figure 1). It displayed a series of images of medications beginning with a box of azithromycin, a broad-spectrum antibiotic used to treat various bacterial infections. The ad was sponsored by Paiz, a Mexican and Central American subsidiary of Walmart, which took advantage of the Instagram Shopping feature: a big red “shop now” button that takes viewers to sites where they can purchase the advertised products. In this post, the price was 15 Guatemalan quetzals (approximately 2 USD) for 30 500-mg tablets of azithromycin. The accompanying caption proclaimed, “Contamos con más surtido para que en tu alacena siempre tengás lo que te gusta” (We offer a greater selection so that you can always have whatever you like in your cupboard). A white label with a red sticker adorned the box. Its small lettering only became legible upon zooming in, reading, “ESTE PRODUCTO SE VENDE SOLO CON RECETA MÉDICA” (This product is sold only with a medical prescription.) Despite the antibiotic's advertised availability, this fine print reflected recent efforts to limit its unrestricted sale in Guatemala. As part of a strategy for combatting rising rates of antibiotic resistance, the Guatemalan Ministry of Public Health and Social Assistance (MSPAS) issued a decree (acuerdo ministerial 145–2019) in June 2019 prohibiting nonprescription sales of antibiotic medications. This was also part of a broader effort among global health institutions and national governments to develop strategic action plans to address antibiotic resistance (Patel et al., 2023).

Months after returning to the United States, I showed the downloaded Instagram advertisement to a group of medical and public health colleagues who regularly encounter antibiotic resistance as an area of research interest and/or of practical concern in clinical contexts. Given their shared understanding that antibiotic overuse and resistance is a serious problem, I was curious to hear their thoughts concerning the clash between governmental policy and corporate agency indexed in this ad. As we spoke, it became an unexpectedly fraught site of ideological work in which “experiences and ideas are swept up—drawn into ideologized interpretations” (Gal & Irvine, 2019, 167). A graduate student, whose research training was in toxicology, remarked that the ad equated antibiotics to other medications sold over the counter in the United States, such as Advil or Tylenol. In response, the medical trainees reflected on the gruesome sequelae of chronic Advil and Tylenol use that they witness in clinical settings. That is, antibiotics were not the only medications in which overuse was a problem. They then debated whether solutions to medication overuse should focus more on public education campaigns or physician-prescribing practices, configuring antibiotic resistance into a targetable problem. Here, the graduate student pointed out that while Tylenol and Advil may have adverse effects, these remained limited within the boundaries of the individual body, whereas antibiotic overuse disrupts an ecology shared among humans and nonhumans. This conversation illuminated for me how meanings about the causes and implications of antibiotic resistance are contested, even among those with scientific and medical expertise that recognized it as a crisis.¹ In this article, I describe the sites of ideological work that have shaped certain meanings and practices associated with antibiotic resistance. These include advertisements, statistical modeling, encounters with antibiotics and antibiotic resistance, and global health interventions. The semiotic activities that construe such sites of knowing and understanding antibiotic resistance as a targetable problem also normalize and sustain the processes that promote an ecology of resistance.

In recent years, infectious disease researchers have declared infections by antibiotic-resistant bacteria to be one of the leading causes of death worldwide (Murray et al., 2022, 629). Counting causes of deaths and mortality at the global scale requires modeling—that is, drawing from a set of assumptions in order to represent a phenomenon.² Such assumptions include the identification of who is doing the counting and who is being counted (Nelson, 2015). While this makes certain things visible, it also eclipses that which is not so readily or easily counted (Wendland, 2016, 77). Statistical modeling in global health also encourages deterministic thinking, which begets a targeted solution to an identifiable problem rather than imagining possibilities for structural change. Yates-Doerr (2020) points out this paradox in social determinants of health (SDOH) frameworks that make economic, political, and other structural factors commensurable within the calculus of global health modeling. Instead, making space for the “material-semiotic indeterminacy” (392) of health matters such as antibiotic resistance brings about an attunement to the less visible, less countable sites in which antibiotic-resistant bacteria incubate and impact human health.

Antibiotic resistance is symptomatic of particular sites of human-microbial entanglements in which bacteria acquire genes that allow them to evade the treatment of commonly used medications. As Wendland (2016, 70) has discussed extensively in the context of maternal mortality, statistical modeling in global health may be more an indicator of the robustness of a nation's infrastructure for such data gathering than for comparing disease burdens between nations. Similarly, identifying antibiotic-resistant bacteria predominantly through their impacts on human disease might eschew the ecology of sites that foment antibiotic resistance, such as subtherapeutic dosing of livestock for growth promotion and pollution of water, soil, and air (Landecker, 2016; Ramay et al., 2020). This is not to negate the role of clinical settings as sites from which antibiotic-resistant bacteria emerge. Rather, I seek to situate clinical and nonclinical sites within a pharmaceutical-industrial ecology of resistance, where sites that produce antibiotic resistance and those where effects of antibiotic resistance manifest are sometimes, but not always, the same. By locating these sites within an ecology, I call attention to the human-microbial entanglements implicated in producing antibiotic-resistant bacteria and human deaths attributable to antibiotic-resistant bacterial infections. The ways in which such entanglements become represented and known—as well as how such representations and forms of knowledge travel—structure the materiality of human and nonhuman biologies. The ways in which such human-microbial entanglements are recognized and made into a target of intervention make certain interactions between humans, nonhumans, and environments more visible than others

For example, a given semiotic reading of a sponsored advertisement on Instagram is shaped by the sites through which antibiotics come to be experienced, known, and valued. For those seeking cures, antibiotics have become a remedy for a broad range of ailments beyond bacterial infection (Geest et al., 1996, 165). As the COVID-19 pandemic spread throughout Guatemala, the MSPAS began distributing “COVID kits” containing antibiotics such as amoxicillin and azithromycin to patients that tested positive for COVID-19 and displayed disease-associated symptoms.³ For US-trained toxicologists, antibiotics are viewed as chemical compounds intended to kill or inhibit growth of bacteria, while also exerting selective pressures that promote the growth of bacterial populations that can evade such mechanisms of action. For physicians, antibiotics take the form of bittersweet pills that promise to eliminate infections, but risk facilitating the growth of antibiotic-resistant bacteria. For a multinational pharmaceutical company, the antibiotic is a commodity, meaning that antibiotic resistance presents yet another profitable opportunity to develop newer classes of antibiotics when older generations cease to be effective.

Specific sites of interaction with antibiotic-resistant bacteria also impact these semiotic readings. At home, an individual medication-user may take antibiotics based on an amalgamation of their perceived bodily condition and previous illness experiences with disease-causing bacteria. Physicians and medical trainees, on the other hand, come to know medications and medicated bodies in ways bound by the structures of hospitals and clinics, where they care for patients with antibiotic-resistant infections. Antibiotic resistance becomes interpreted as a problem of medication overuse, much as chronic overuse of pain relievers such as Tylenol and Advil are. While the latter medications do not promote bacterial resistance in the way that antibiotics do, physicians observe and learn about the sequalae of chronic medication overuse through their clinical encounters. Thus, they similarly assign blame to overuse in both cases, whether due to physician overprescribing or patient self-medication.⁴ Scientists studying molecular mechanisms of antibiotics and resistant genes in laboratories observe the interactions between antibiotics and bacteria. While they do not necessarily confront the acuity of sick patients in clinical settings, they might instead see antibiotic resistance as phenomena that occur in multiple sites. As one student from this disciplinary background commented in our discussion of the Instagram ad, events of antibiotic resistance often take place outside the walls of biomedical institutions. Patients get infections and take their medications beyond the purview of physician supervision. Bacteria, pills, and antibiotic resistance travel across bodies, homes, labs, and hospitals. This is not to say that this perspective is exclusive to scientists, nor that physicians do not see antibiotic resistance as an ecological, multisited process. Rather, I contrast these interpretive lenses to highlight the embodied practices and discourses that frame how those inhabiting different roles of treatment seekers, healthcare providers, and researchers come to experience antibiotic resistance.

Forms of expert knowledge about a topic such as antibiotic resistance are situated practices of studying and conceptualizing interactions between bacteria and antibiotics (Haraway, 1988). When these forms of expert knowledge shift from their sites of practice to those of political and economic implementation, they acquire new social meanings and values. Scientific discourses about infectious disease hold symbolic authority within Global North ideologies based on who is considered a producer of knowledge and how ideas about the transmissibility of microbes may become communicable (Briggs, 2005; de Certeau, 1984). Public narratives of infectious disease are powerful sites for ideologized interpretations of how diseases travel and what forms they take on. For instance, Briggs and Mantini-Briggs (2003) describe how Vibrio cholerae was transformed by media narratives in the early 1990s from a cholera-causing bacteria responsible for an international epidemic into a signifier attached indexically to the isolated, indigenous Warao residents of Venezuela's Delta Amacuro. Cholera became a site for pathologizing indigenous practices rather than revealing a lack of funding for healthcare infrastructure and the poor response to the unfolding epidemic in the region. Similarly, Dewachi (2019) investigates how popular US media narratives transformed Acinetobacter baumannii, a “superbug” notorious for its high levels of resistance to multiple antibiotics, into a semiotic tool for making intelligible the effects of war on soldiers’ bodies. These narratives used the moniker “Iraqibacter” to signify Acinetobacter as an infection invading military hospitals and personnel during the US invasion of Iraq. For the US public, the communicability of Acinetobacter’s acquisition of drug resistant genes amplified a wartime political ideology in which “Iraq” came to signify “threat.” However, the iconic superbug did not erupt out of the Iraqi soils. It was produced by decades of sanctions and militarization in Iraq, in which US ideologies and practices weakened healthcare infrastructures, facilitated antibiotic misuse, and contaminated environments with heavy metals. These ethnographic examples illustrate how the transfer of expert knowledge across sites of production to those of socioeconomic and political application is semiotically mediated by ideological frameworks. Questions about human-microbial interactions are “rendered technical” by the scales and methods of producing knowledge about, for instance, cell signaling and gene transfer, eclipsing the political contestations that also shape such molecular interactions (Li, 2007, 7).

Recent efforts to preserve the diversity of microbial ecologies provide another example of how human-microbial-antimicrobial interactions have been rendered technical, obfuscating the political causes and consequences of a pharmaceutical-industrial ecology. Within the human body, microbiomes facilitate physiological processes such as digestion, metabolism of nutrients, immune system function, and reproduction (Cho & Blaser, 2012; Ursell et al., 2012). However, as one student alluded to in our conversation, antibiotic resistance is one of many factors that scientists have linked to the degradation and diminishing diversity of microbiomes—that is, the communities of bacteria residing within human bodies and surrounding environments. This has prompted increased attention to the production of knowledge comparing the biodiversity of microbiomes in “westernized” and “nonwesternized” populations (Clemente Jose et al., 2015). While these research and conservation efforts are aimed at accumulating reserves of ancestral microbes (e.g., the Global Microbiome Conservancy), such practices and discourses of biobanking also entail a typification of populations with the “least exposure to urbanization” (Dominguez-Bello et al., 2018, 34). Alongside their recommendations for microbial stewardship that include practices such as the reduction of antibiotic overuse, advocates for microbiome banking propose that safeguarding ancestral microbes holds the promise of restoring depleted urban, industrial microbiomes.⁵ Microbiome restoration efforts reimagine microbes as something transplantable, accumulable, and characterizable as “Indigenous,” “non-Western,” and “traditional.” This raises questions about how and by whom such significations will be determined, who will benefit from them, and what are alternative modes of microbiome restoration beyond biobanking. Scientific discourses about microbial stewardship and concerns over antibiotic resistance identify the political economic processes at play in shaping human and nonhuman microbiomes within a pharmaceutical-industrial ecology. However, they depoliticize and dehistoricize the signification of “indigeneity,” rendering “Westernization,” and “urbanization” into determinants that can be targeted through technical solutions such as the restoration of human microbiomes, rather than addressing the sociohistorical processes that have produced contemporary microbial ecologies.

In addition to rendering technical political contestations, the discourses resulting from the shifting of expert knowledge from sites of practice to those of policies and interventions manifest apparent contradictions. The Instagram advertisement that I opened this essay with demonstrated such a contradiction in its simultaneous display of the marketing of antibiotics and efforts to reduce antibiotic resistance through policies such as prohibitions on nonprescription sales of antibiotics. The ad displayed antibiotics as both items to be regularly stocked in one's cupboard and as medications whose sale is to be regulated by physician prescription. This dual messaging encapsulates the various shifts in the status of this microbe-targeting pill from one of regular, individual self-care to a substance to be judiciously administered by an expert. In 1977, the World Health Organization (WHO) published its first Essential Medicines List, which included antibiotics among other medications. This also marked a transition in the status of the pill from that of a commodity produced by profit-driven pharmaceutical companies to that of a health essential alongside water, food, and shelter (Greene, 2011, 25). Making antibiotics essential materialized in the emergence of public–private and philanthropic relationships between pharmaceutical companies, international health organizations, and national healthcare systems. This “pharmaceuticalization of public health” (Biehl, 2007) rendered structures of poor health conditions such as insecure water, food, and housing access into targetable problems to be remedied in part through antibiotics. However, amid growing concerns over antibiotic resistance and overuse of such pills, the WHO has revised its criteria for antibiotics as essential medicines. These updated criteria employ stricter guidelines for reducing their unnecessary and inappropriate use, such as through greater incorporation of laboratory diagnostics and stricter requirements on who can dispense antibiotics (WHO, 2021). Thus, the shifts in the semiotics of the pill from commodity to health essential to regulated substance have also prompted restructurings in the constellation of programs, practices, and materials that constitute global health. The marketing of antibiotics as a household staple reflects the decades in which health increasingly became a practice of individual self-care and consumption. Further investigation is needed to know if online vendors have implemented measures to prevent nonprescription sales of antibiotics via platforms such as Instagram Shopping, as well as how consumers have responded to them. Nonetheless, a semiotic analysis of this social media advertisement reveals how an ideology and media landscape of consumption overshadows measures to curtail antibiotic use. This also points to the limits of solutions that identify antibiotic resistance as a problem of unregulated consumption and attempt to intervene through prohibiting nonprescription sales.

In assembling and analyzing antibiotic advertisements, scientific literature, and global health policy guidelines as sites of ideological work, this essay demonstrates how the semiotics of human-microbial entanglements form the grounds for the types of interventions that aim to address antibiotic resistance. These sites are areas in which the boundaries and scales of human-microbial relationships are multiple, contested, and made intelligible. Antibiotic overuse is a clinical problem that affects individual patients. It is also an ecological one that alters microbial evolution beyond the site of the clinic. Microbiome banking reimagines processes that incubate antibiotic resistance (“urbanization” and “Westernization”) as determinants that can be remedied through accumulation and restoration of ancestral microbes. Sites of discourse circulation—whether they be social media platforms or essential medicines lists—structure the semiotics of antibiotics as health essentials, substances to be regulated, or marketable commodities. The diverse modalities through which human-microbial entanglements are expressed, who determines such modalities, and the layers of semiosis involved in interpreting them provides insight into how efforts to address antibiotic resistance are structured by discourses that simultaneously perpetuate a pharmaceutical-industrial ecology. Attending to these modalities might illuminate traces of things left unsaid and intimations of alternative modes of knowing and being. Just as public health is about more than stocking essential medicines in one's cupboard, understanding antibiotic resistance requires attention to the sites, structures, and indeterminate entanglements within a pharmaceutical-industrial ecology that promote resistance.