Antibiotic resistance: thinking about humans in the environment

It may seem sur­pris­ing that philo­sophy is inter­ested in anti­bi­ot­ic res­ist­ance. How­ever, this pub­lic health prob­lem ques­tions our rela­tion­ship with health­care, our rep­res­ent­a­tions of dis­ease, and the pos­i­tion of humans with­in the com­munity of liv­ing beings. Mira­cu­lous in terms of effect­ive­ness, we must nev­er­the­less start by recall­ing that anti­bi­ot­ics are only one thera­peut­ic option among oth­ers. Although less spec­tac­u­lar, these oth­er options should not be overlooked.

In Europe and North Amer­ica, approaches such as san­it­ising oint­ments or phages were aban­doned. The lat­ter, which uses deadly vir­uses against tar­geted bac­teria, was a par­tic­u­larly developed tech­nique in the Soviet world. Its com­plex pre­scrip­tion and par­tic­u­lar logist­ics do not in them­selves explain why it was aban­doned in favour of anti­bi­ot­ics. The polit­ic­al con­text at the time and the Cold War must also be considered.

The spe­cificit­ies of our West­ern cul­ture com­bined with the eco­nom­ic interests of the time favoured the devel­op­ment of anti­bi­ot­ics. When peni­cil­lin pro­duc­tion was indus­tri­al­ised in the 1940s¹, mod­ern medi­cine was happy to be able to offer a stand­ard­ised product that could cure an infec­tion with­in days. The incid­ence of infec­tion-related deaths fell and anti­bi­ot­ic use became widespread.

Indus­tri­al­ised coun­tries have massively expor­ted this stand­ard­ised ther­apy to low-income coun­tries to treat infec­tious dis­eases. Very quickly, how­ever, coun­ter­feit or under-dosed drugs appeared on the mar­ket, con­trib­ut­ing to the emer­gence of resistance.

Look­ing bey­ond eco­nom­ic profit, it is our way of under­stand­ing bac­teria and our vul­ner­ab­il­it­ies that anti­bi­ot­ic res­ist­ance calls into ques­tion. Sci­ent­ists have known since the dis­cov­ery of anti­bi­ot­ics that their unreas­on­able use and mis­use ulti­mately threaten their effect­ive­ness. How­ever, they have been, and some­times still are, admin­istered pre­vent­ively to avoid sec­ond­ary infec­tion, even in patients without risk factors, or massively in live­stock until the early 2000s in Europe².

Human and veter­in­ary medi­cine has long prac­tised, without tak­ing into account its envir­on­ment, even its imme­di­ate envir­on­ment, neg­lect­ing the equi­lib­ri­um of the micro-organ­isms (patho­gen­ic or not) with which we cohab­it. The philo­soph­er of bio­logy Thomas Pra­deu ques­tions these bound­ar­ies between ‘self’ and ‘non-self’³. Are these terms appro­pri­ate when the pres­ence of these microbes is essen­tial for our survival?

Nev­er­the­less, the vocab­u­lary in the field is viol­ent, using a war­like lex­ic­al that evokes infec­tious agents. Medi­cine and hygien­ism ‘fight-against’ rather than ‘deal-with’ bac­teria, so advoc­at­ing their erad­ic­a­tion in the col­lect­ive con­scious­ness. These rep­res­ent­a­tions hinder our curi­os­ity about liv­ing things and our propensity to seek bal­anced rela­tion­ships in biodiversity.

WHO warns of the risk of a post-anti­bi­ot­ic era, in which doc­tors would lack effect­ive molecules. The crisis is ser­i­ous, even though it was fore­see­able, even anti­cip­ated. « Why have we been blind to it » is the first ques­tion that need to be answered when con­sid­er­ing the phenomenon.

This cog­nit­ive dis­so­ci­ation is not unre­lated to our mech­an­ist­ic con­cep­tion inher­ited from Cartesian philo­sophy. When René Descartes depic­ted human­ity as being rad­ic­ally sep­ar­ated from the rest of the liv­ing world in the early 17th cen­tury, he estab­lished that the pur­pose of acquir­ing know­ledge is to mas­ter nature, pre­cisely for the sake of human health, « which is undoubtedly the first good and the found­a­tion of all the oth­er goods of this life« ⁴.

Although this think­ing has been con­stantly chal­lenged by research in eco­logy and bio­logy, it remains cent­ral to when it comes to train­ing doc­tors and veter­in­ari­ans. Without belittling it, it does, nev­er­the­less, favour a type of care ori­ented towards “tech­nique” rather than “rela­tion­ship”.

The social sci­ences have shown, how­ever, that depend­ing on wheth­er a per­son’s beliefs are ori­ented towards sci­ence, con­spir­acy the­or­ies or scep­ti­cism, his or her beha­viour in rela­tion to anti­bi­ot­ic pre­scrip­tions will change.

Anti­bi­ot­ic res­ist­ance thus raises eth­ic­al ques­tions, and prac­ti­tion­ers will have rethink their role as care­givers bey­ond their tech­nic­al role as “heal­ers”. It also calls into ques­tion the cur­rently unbal­anced doc­tor-patient rela­tion­ship and encour­ages co-con­struc­tion of care, even in the choice of pre­scrip­tions⁵.

A carer is not a carer if he does not feel cared for by the per­son being cared for, as the psy­chi­at­rist Jean Oury eleg­antly put it. Thus, when we expect doc­tors or veter­in­ari­ans to ‘edu­cate’ their patients or cli­ents so that they do not unduly demand anti­bi­ot­ics or use them bet­ter, we mis­un­der­stand what is at stake.

Rebuild­ing our rela­tion­ship with care would there­fore undoubtedly open the way to more pro­found and last­ing changes in beha­viour than man­age­ment approaches are cap­able of doing. Approaches that are cur­rently being adop­ted both by insti­tu­tions and by many experts are the best way to respond to the anti­bi­ot­ic-res­ist­ance health situ­ation. More inclus­ive approaches, such as « One Health« ⁶ are among the most inter­est­ing soci­et­al approaches to invest in, provided that they go bey­ond mere win­dow-dress­ing to build a real col­lect­ive philo­soph­ic­al investment.