Tiia Sudenkaarne locates a lacuna in moral theory and demonstrates the need for a new and intersectional queer, feminist and posthuman approach to understanding antimicrobial resistance
The Problem of AMR
The World Health Organisation (WHO) has declared that antimicrobial resistance (AMR) is “one of the top ten global public health threats facing humanity” (2021). AMR occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines, making infections harder to treat and increasing the risk of disease spread, severe illness and death. However, this dominant understanding of AMR only covers one aspect of microbial resistance. The current definition of AMR lacks understanding of more-than-human animals, multi-species perspectives, and eco-systems. This definition also needs to address human health.
To foreground a more-than-human approach, the environment must be seen also as key to the development, transmission and spread of AMR to humans, more-than human animals and plants (UN Environmental Report 2022, 1). Many human activities create pollution which promotes the emergence of AMR in the environment and can cause animal or plant diseases or soil biodiversity loss. This leads to further use of antimicrobials that only increases the selective pressure across eco-systems. This problem of scale directly relates to social inequalities in low- and middle-income countries. The impact is especially pronounced in African countries, in particular (Sariola et al 2022). Calibrating a society toward thinking critically about and through AMR resilience and prevention requires attention to species interdependencies (Haraway 2008; Chandler et al 2016; Brives et al 2021).
In my view, a more-than-human or “multi-species” approach demands attention to new moral theories, which I argue should be at the centre of conversations about AMR. Such a perspective, attuned to both social and multispecies justice, is crucial to show how seemingly unified stakeholders, such as power structures within human networks or similar more-than-human networks, have intersecting, layered vulnerabilities that align with existing social justice issues reproduced by the concept of race, ability/embodiment, and gender and sexuality (cf. McKnight 2022; Will 2018; Sariola et al 2022). In such structures, reproduced through social practice, those already marginalized are at higher risk to become vulnerablized (Tremain 2021), such as sex workers. For example, Manuya and colleques (2022) have shown how with the threat of AMR and entrenched gender disparities, sex workers are vulnerable to greater surveillance, stigmatization, and criminalization “to control both infections and women”. This also reveals a lacuna of queer positioning in AMR frameworks, including mapping out specific needs and vulnerabilities (cf. Charles et al. 2022; Yingwana 2022). Further, such a framework should be able to address multispecies vulnerabilities. Vulnerabilities cascade (cf. Luna 2018) following social-scientific patterns but also take on new layers in AMR. For example, McPherson and colleagues (2021) have identified specific ‘antibiotic vulnerabilities’ and studied ways in which to reveal how antimicrobial provision in rural Malawi impacts care in conditions of extreme scarcity.
A Queer, Feminist, Posthuman Framework
As I have suggested in my previous work (Sudenkaarne 2021), a queer feminist framework for vulnerability and a moral theory building on the premise of gender and sexual variance as a necessary condition, are crucial contributions to AMR or any other ethical crisis of our time. It is a platform for orienting a multispecies justice (cf. Chao et al 2022) while staying with the trouble (cf. Haraway 2016). This means that we must accept that there is complexity and tension within a phenomenon like AMR – and these tensions can be addressed within a justice-oriented framework. To decolonial feminism philosopher Maria Lugones (2007, 202), cis- and heteronormativity continue to be downplayed despite their “consistently perverse, violent, and demeaning, turning people into animals and turning white women into reproducers of the (white) race and the (middle or upper) class” (see also Sudenkaarne and Blell 2021). This suggests a morally salient yet volatile nexus between a multispecies approach, reproductive justice orientation and decolonial framework, class politics and a queer feminist posthumanist framework that I plan to consider further.
On the (critical) posthumanist (Sands 2022) component of my framework, posthumanism offers a context, firstly, to situate the dilemma between human-centered health and a One Health approach. This stance positions the inseparability of the health of humans, non-human animals and the environment as its core premise in a holistic understanding (Cañada et al 2022, 1). Secondly, posthumanist imaginations strive for futures and presents with human impact builds on post-anthropocentrism with a feminist orientation (Braidotti 2021). The One Health approach to AMR is an idea for doing prevention ethics (Cañada et al 2022) and also a management framework that acknowledges and engages with the role of AMR transmission. Conflicting definitions of a One Health approach exist (Johnson and Matlock 2023, 23), and thus agreeing to a posthuman, multi-species approach may enable critical insight into this urgent problem. However, if this problem is only understood within a managerial framework, ethical contemplation of AMR-reducing initiative will only prioritize the impact of change in the use of antimicrobials on human health (Cañada et al 2022: 1-2). We need different ways of thinking and doing AMR ethics both in theory and in prevention and management practice.
The One Health framework remains ambiguous in terms of moral theory – perhaps an emergent idea for ethical inquiries rather than a consistent ethical framework (van Herten et al. 2019). It can be argued that posthumanism can and, indeed, should inform the conversations around life, subjectivity, human nature, responsibility, and interspecies relations that underpin bioethical decision-making (Sands 2022, 1) around AMR.
Towards Nonhuman Justice
As I have discussed, there is a lacuna in moral theory to navigate gender and sexual variance as a normative component when addressing phenomena like AMR that demand answers to core philosophical questions. What kinds of subjects can we imagine as morally significant? How are multispecies relations managed without prioritizing human ways of being? How are intersecting layers of vulnerabilities minimized between groups of people? Is species an oppressive category or needed to ground subversive politics? How to move from human-oriented use of technology to solutions benefitting the entire global ecosystem? Crucially, a justice orientation more committed to nonhuman moral significance does not lessen human accountability. On the contrary, it means that accountability requires much more attentiveness to existing power asymmetries (Barad 2007, 219). An open, communal and collaborative process, building a queer feminist posthuman framework aims to make the case for posthuman moral responsibility, further enhancing the One Health aim of AMR policies.
About the Author
Tiia Sudenkaarne is a postdoctoral researcher at University of Helsinki, Finland. She is currently with the research project CrimScapes: Navigating Citizenship through European Landscapes of Criminalisation, funded by NORFACE. It is one of the projects linked to the Center for the Social Study of Microbes, funded for University of Helsinki by Wellcome Trust. She is also a grant researcher in the project Technology, Ethics and Reproduction: Controversy in the Era of Normalization funded for Tampere University, Finland, by Kone Foundation. Her research interests include feminist philosophy, queer theory, feminist bioethics, queer bioethics, moral theory, gender studies, sociology of reproduction, and feminist science and technology studies. She is currently thinking about vulnerability in AMR in relation to gender and sexual variance, about microbial ethics, and about multispecies care.
Image courtesy of Microbimpro by artist Oona Leinovirtanen, one of the CSSM artists-in-residence (2023).
Barad, Karen. 2007. Meeting the Universe Halfway: Quantum Physics and the Entanglement of Matter and Meaning. Durham: Duke University Press.
Braidotti, Rosi. 2021. Posthuman Feminism. Oxford: Policy Press.
Brives, Charlotte, Matthäus Rest and Salla Sariola, eds. 2021. With Microbes. London: Mattering Press.
Cañada, Jose, Salla Sariola and Andrea Butcher. 2022 “In Critique of Anthropocentrism: a More-Than-Human Ethical Framework for Antimicrobial Resistance.” Medical Humanities Published Online First: March 23rd, 2022. 10.1136/medhum-2021-012309.
Chandler, Clare I.R., Eleanor Hutchinson, and Coll Hutchison, eds. 2016. “Addressing Antimicrobial Resistance Through Social Theory: An Anthropologically Oriented Report.” London School of Hygiene & Tropical Medicine. Available online at http://www.lshtm.ac.uk/php/ghd/research/app/anthropologyofantimicrobiaresistance.htm
Charles, Hannah, et al. 2022. “Outbreak of Sexually Transmitted, Extensively Drug-resistant Shigella Sonnei in the UK, 2021-22: a Descriptive Epidemiological Study.” Lancet Infectious Diseases (10): 1503-1510.
Chao, Sophia, Karen Bolender and Eban Kirksey, eds. 2022. The Promise of Multispecies Justice. Durham: Duke University Press.
Haraway, Donna. 2008. When Species Meet. Minneapolis: University of Minnesota Press.
Haraway, Donna. 2016. Staying with the Trouble: Making Kin in the Chthulucene. Durham: Duke University Press.
Johnson, Tess and William Matlock. 2023. “Justifying the More Restrictive Alternative: Ethical Justifications for One Health AMR Policies Rely on Empirical Evidence.” Public Health Ethics 16(1): 22–34.
Lugones, Maria. 2007.” Heterosexualism and the Colonial/Modern Gender System.” Hypatia 22(1): 186-209.
Luna, Florencia. 2018. “Identifying and Evaluating Layers of Vulnerability: A Way Forward.” Developing World Bioethics 19(2): 1–10.
MacPherson, Eleanor, Joanna Reynolds, Joanna, Esnart, Sanudi, Alexander Nkaombe, Chimwemwe Phiri, John Mankhomwa, Justin Dixon, and Clare Chandler. 2021. “Understanding Antimicrobial Resistance through the Lens of Antibiotic Vulnerabilities in Primary Health Care in Rural Malawi.” Global Public Health 17(11): 2630-2646.
Manyau, Salome, Justin Dixon, Norest Mutukwa, Faith Kandiye, Paula Palanco Lopez, Eleanor E. MacPherson, Rashida A. Ferrand, and Clare I. R. Chandler. 2022. “Antibiotics and the Biopolitics of Sex Work in Zimbabwe.” Medical Anthropology 41:3, 257-271.
McKnight, Ulla. 2022. “Replacement Feeding and the HIV Diaspora: A Case of Ontological Multiplicity and Fluid Technologies.” Sociology of Health & Illness (44): 169– 187.
Muna, Anjum F., Heike Schmitt, Stefan Börjesson, and Thomas U. Berendonk. 2021. “The Potential of Using E. Coli as an Indicator for the Surveillance of Antimicrobial Resistance (AMR) in the Environment.” Current Opinion in Microbiology 64: 152-158.
Rogers, Wendy A., Jackie Leach Scully, Stacy M. Carter, Vikki A. Entwistle and Catherine Mills, eds. 2023. The Routledge Handbook of Feminist Bioethics. London: Routledge.
Sands, Danielle. 2022. “Introduction: Encounters Between Bioethics and the Posthumanities.” In Bioethics and the Posthumanities, edited by Danielle Sands, 1-13. London: Routledge.
Sariola, Salla, Andrea Butcher, Jose Cañada, Mariette Aïkpé and Adélaïde Compaore. 2022. “Closing the GAP in Antimicrobial Resistance Policy in Benin and Burkina Faso.” American Journal of Microbiology 7(4): e00150-22.
Sudenkaarne, Tiia and Mwenza Blell. 2021. “Reproductive Justice for the Haunted Nordic Welfare State: Race, Racism, and Queer Bioethics in Finland.” Bioethics 36 (3): 328-335.
Sudenkaarne, Tiia. 2021. Queering Bioethics: A Queer Feminist Framework for Vulnerability and Principles. Doctoral Dissertation. Reports from Department of Philosophy 47, University of Turku, Finland.
Tremain, Shelley. 2020). “Covid-19 and the Naturalization of Vulnerability.” Biopolitical Philosophy Blog.
UN Environment Program. 2022. “Environmental Dimension of Antimicrobial Resistance: A Summary for Policymakers.” https://wedocs.unep.org/bitstream/handle/20.500.11822/38373/antimicrobial_R.pdf.
van Herten, Joost, Bernice Bovenkerk and Marcel Verweij. 2019. “One Health as a Moral Dilemma: Towards a Socially Responsible Zoonotic Disease Control.” Zoonoses Public Health 66: 26– 34.
WHO. 2021. “Antimicrobial Resistance.” Last modified November 17th, 2021. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance.
Will, Catherine. 2018. “Editorial: Beyond Behavior? Institutions, Interactions and Inequalities in the Response to Antimicrobial Resistance.” Sociology of Health and Illness 40: E1-E9.
Yingwana, N. 2022. “Queering Sex Work and Mobility”. Anti-Trafficking Review 19: 66-86.