Eleanor Kashouris reports on the 2022 Marginalisation and the Microbe Conference at Brighton and Sussex Medical School.
The Marginalisation & the Microbe conference took place in late November 2022 as part of a Wellcome Trust funded project on marginalisation and healthcare in crisis. Co-hosted by the Brighton and Sussex Medical School and the Sociology and Criminology Department at the University of Sussex, the conference brought together social scientists, clinicians and bioethicists in an interdisciplinary space. The conference was organised to discuss ongoing concerns about antimicrobial resistance (AMR), the Covid-19 pandemic, marginalisation and healthcare. We asked speakers to consider how they negotiate uncertainty in their practice relating to health inequalities, biomedical technologies and medicines and/or AMR over four interdisciplinary panels on bladder health, borders and category-making, ethical issues and anticipating the future.
Infectious Diseases specialist Chi Eziefula chaired the first session on ‘Bladder Health’. Eleanor Kashouris started the session by expressing uncertainty about how best to conceptualize patients and patienthood, noticing when the concept of patienthood allows for recognition of people in need of care, but also discomfort with how patient experience of illness is often conceptualised as a subjective additive to objective facts about disease. Clinical microbiologists Annie Joseph and Tom Lewis ran us through the uncertainty that arises in diagnosing urinary tract infection (UTI) when symptoms poorly correlate with measurements of bacterial abundance in the urinary microbiome. They offered reflections on ways they find to go forward in caring for patients, amidst this uncertainty. Finally, Paula Saukko showed us how diagnosis of UTI in hospital settings subverts traditional analyses of how diagnosis is done between clinical signs and data from diagnostic technologies, and paid attention to what happens when clinical signs are doubted, especially in the case of older women.
Catherine Will chaired the second session on ‘Borders, Barriers and AMR.’ To start, Alena Kamenshchikova reflected on where, and in which bodies, resistant bacterial organisms are imagined to lie, drawing attention to the consequences of this for people targeted for surveillance, and for mobilisations against AMR. A link between Alena’s work and the next presentation, by Ulla McKnight, came in the difficulties of knowing AMR, compared to the ease of identifying familiar targets of intervention in public health. Ulla traced the tricky story of Mycplasma genitalium and her talk generated much discussion on the precise nature of missing knowledge as she pointed out that quantum physicists have an example to contribute of ways to work with unknown knowledge in their concept of ‘dark matter and dark energy.’ Infectious diseases specialist Martin Llewelyn then questioned how to reduce antibiotic use safely. Detailing extensive reasons why traditional clinical trials do not provide answers to this question, Martin raised significant ethical and methodological problems with knowing what we need to know. Fitting with the theme of the conference on uncertainty, Martin ended his presentation not with answers but with two dilemmas: how to balance societal risks of AMR against potential individual benefits of antibiotic use and how to design research which can ethically provide answers to the question of how to reduce antibiotic use safely.
Chase Ledin chaired the third session on the ‘Next Big Thing’. Anticipating futurity, Suneeta Soni and Daniel Richardson, specialists in sexual health medicine respectively grounded their presentations in a case study of a young cis woman, and the issue of enteric infections in men who have sex with men. They guided us through the challenges they face in their clinics, and contemplated the future as antibiotics come under increasing pressure. Then Marsha Rosengarten followed by reflecting on the divergent ways the problem of rising sexually transmitted infections (STIs) and potential antibiotic resistance is approached within the field of study of the human immunodeficiency virus (HIV). Marsha contemplated how pre-exposure prophylaxis (PrEP), AMR, STIs, HIV and antibiotics come together and touch each other, and how it is decided what matters in the forging of this web of relations.
Bioethicist Bobbie Farsides chaired the final session on ethics and humanities relating to AMR and the wider public health setting. During this session, Peter West-Oram set out a careful theory of solidarity, differentiating it from charity and arguing that solidarity may provide an impetus for action on AMR. Patricia Kingori then presented fascinating work following two drugs across continents, from sea ports to the ‘last mile’. She encouraged us to think about what we talk about when we talk about fakes and fakery in global health, paying more attention to sub-standard drugs compared to fakes. Finally, Jessica Nihlén Fahlquist ended the conference for us with a careful philosophical account of how to approach collective complex societal problems such as AMR. Jessica spoke to the different roles of individuals and governments in balancing risk and responsibility, raising some of the important issues of ethical uncertainty around AMR.
Overall, when we think about what we do in academia, and how we navigate uncertainty, it is often important to recognise that while we work largely in the critical mode, our clinical colleagues are making high-stakes decisions with important consequences every day, and often without the resources or knowledge needed to ensure a good decision. At the same time, the boundaries are blurred as we all attempt to navigate difficult relationships and ethical issues in our research and our daily lives. What we can usefully do as social scientists and ethicists is take time for slow and reflective thinking about complex issues. Mobilising against AMR, Covid-19, and other health crises without increasing health inequalities would require careful thought from interdisciplinary perspectives. The Marginalisation and the Microbe conference provided a moment to think together, across disciplines, about the futures we face, the unequal distribution of risk, and what we might do to anticipate risk without re-inscribing and re-affirming inequality.
Together, the organising team would like to thank: all of the participants in the research, participating NHS trusts and clinical collaborators, the project advisory board, Jane Hanson LCRN Kent, Surrey and Sussex NIHR, Jane Anderson at Homerton University Hospital NHS Foundation Trust, the Wellcome Trust for funding and supporting the research, Brighton and Sussex Medical School, the Department of Sociology and Criminology at the University of Sussex, Dustin Banks for the project artwork and Matt Bemment, BSMS Digital Comms Officer, for his extensive tech, marketing/comms, and organising support before, during and after the event.
About the Team
The conference was organised by Ulla McKnight, Eleanor Kashouris, Catherine Will and Bobbie Farsides. You can find out more about the project on the project website or the project Twitter @AMRinterrupted. You can view recordings of the conference on YouTube.