Scalability and partial connections in tackling antimicrobial resistance in West Africa

Jose A. Cañada


Long-distance translocation of [antimicrobial resistant] bacteria between systems and countries is also possible. One route by which this might happen occurs when waterborne bacteria become airborne either through bubble bursts or convection. Once the bacteria are airborne, air currents can move them over long distances before redepositing them. However, a more probable route of long-distance dissemination is through anthropogenic movements of vectors such as aquatic animals and plants, for which there is large-scale international trade (Taylor, Verner-Jeffreys, and Baker-Austin 2011: 281).

Microbes and, more specifically as described in the excerpt above, resistant bacteria travel. However, they do not travel alone. Water and air flow as well as the human transportation of other animals and plants all play key roles in understanding the global spread of antimicrobial resistance (AMR). AMR refers to microbes – bacteria, fungi and viruses – becoming resistant to the mechanisms that kill them. When formulated as a health issue, AMR is usually reduced to bacterial infections and antibiotics, but resistant bacteria are not the only elements of AMR subject to translocation. Given the potential ubiquity of AMR described in the excerpt above, actions aimed at tackling resistance attempt to span the globe and to identify the many sectors involved, affected or responsible. This produces a back and forth between global and local scales of AMR enactment that forces us to think about the various contexts in which AMR and the actions to tackle it are situated. In my work, I have attended to those multi-context dynamics by following the implementation of global AMR policy initiatives in two West African countries (Benin and Burkina Faso), looking at how the actions and changes proposed from global health initiatives meet with the situated local materialities of the patients, breeders, veterinarians, healthcare workers and researchers who are pulled into the AMR challenge by global health organisations.

Exploring the emergence of these multiscalar contexts at the global and local levels contributes to what Anna Tsing (2005) has called an ‘ethnographic examination of scale making, […] the study of the messy and effective encounters and translations of globalist projects’, according to Warwick Anderson (2014: 378). Tsing’s thoughts on scalability are particularly interesting if we apply her ‘theory of nonscalability’ (Tsing 2012), which carries special significance in the context of top-down projects such as AMR. For Tsing, nonscalable elements are not easily transplanted between contexts, since they often ignore the relationalities which render such contexts unique. In this chapter, I examine how certain objects crucial to the AMR globalist project are recognisable and identifiable across the globe, yet, when exposed to local contexts and their complex relationalities, become nonscalable. That is, they struggle to fit with the situated sociomaterialities that AMR actors are embedded in. In this attempt, I do not merely illustrate how global health – and the global issue of AMR more specifically – is made in local contexts, but the problems that objectivist projects common in the governance and regulation of microbiological entanglements run into when framed using standardised scientific narratives.

Probably the most visible element in the regulation of microbiologically defined threats to health has been the Global Action Plan for AMR (GAP), published by the World Health Organisation (WHO) in 2015, which was in the process of being adapted into a national action plan during my fieldwork in Benin and Burkina Faso. Although resistance in bacteria is a naturally occurring phenomenon resulting from selective pressures (Prestinaci, Pezzotti, and Pantosti 2015), GAP calls attention to the effect of human practices, specifically antibiotic use. More concretely, these practices include the misuse, overuse and abuse, purchase without a prescription, or the commercialisation of ‘fake’ antibiotics with less active components than required. Such practices help to kill non-resistant bacteria while leaving resistant strains alive and capable of reproducing and spreading resistance genes. Although these are practices to avoid from a global framework perspective, for local actors like those featured in this chapter, they are key elements to compensate for the lack of infrastructures that characterise precarious settings. Reliance on antibiotics represents a ‘quick fix’ in antibiotic policy that largely ignores the socio-political conditions surrounding AMR (Denyer Willis and Chandler 2019), putting emphasis on the individual and framing the issue in behavioural terms (Pearson and Chandler 2019).

GAP presents specific challenges that extend beyond the usual problems associated with global health policy implementation in the context of infectious diseases (Cañada 2019) – challenges stemming from GAP’s multisectoral character. The signing by a so-called tripartite collaboration between the WHO, the Food and Agriculture Organisation (FAO) and the World Organisation for Animal Health (OIE) represented a turning point for AMR and its formulation. The involvement of FAO and OIE at an international level translates into a need for interministerial collaboration at a national level and the establishment of several focal points, which impacts multiple economic sectors. Ministries of health, often the sole agencies responsible for translating WHO initiatives into action, must collaborate with ministries of agriculture, fishing, animal production and the environment. Thus, the policy processes initiated by GAP activate horizontal coordination mechanisms that challenge typical intragovernmental dynamics of collaboration, something the policymakers that I spent time with struggled to incorporate into their everyday practice.

In the absence of a recognition of local socio-material conditions, discourses of behaviourism and the cherishing of available antibiotics remain dominant in policy settings. However, alternative discourses exist. These discourses primarily engage with a redefinition of immunity and the consequent modes of coexistence with microbes. Current understandings of gut microbiota and the human-microbial entanglements we humans define as healthy are expanding in new directions. The existing literature argues for a need to understand bacteria not only through their pathogenic threats to human health but also through the crucial roles they play in producing functional immune systems (Lorimer 2017; Pradeu 2012). The policies and implementations analysed here are instead framed as a fight for survival which characterises the dynamics of resistance (Beisel 2017). In the AMR narrative, the fight against microbes cannot be won. Instead, that fight becomes a matter of optimising the tools available to regulate human-microbial entanglements (and the mediating role of animals) in ways that do not render those tools ineffective. A similar fight for survival characterises the drive and motivation of local actors to engage with AMR. However, their survival is not only uncertain because of the threat posed by microbes, but because of the constant demands exerted by global initiatives to alter their situated practices, which put their livelihoods at risk.

In this chapter, I look beyond the typical technical character of AMR policies, which tend to provide a rather static image of the most prominent actors in this volume: that is, microbes. In the technical worlds built by global health policymakers to deal with AMR, little space exists for a dynamic and complex understanding of microbes themselves, as well as the communities in which those microbes emerge as relevant actors. By attending to locally situated experiences of AMR across different human collectives, I bring to life the technical and dry narratives of microbes that feature in global policy. Doing so helps me to illustrate why global detached accounts of human-microbial relations give rise to measures and proposals that, on encountering locally situated materialities, are instantly rendered nonscalable.

In the following section, I find inspiration in the notion of ‘assemblage ethnography’ (Youdell and McGimpsey 2015) to formulate how the emergence of nonscalable elements can be considered analytically and methodologically. I also describe the specific empirical material used in this chapter. The subsequent empirical section is divided into three parts illustrating various nonscalable dynamics affecting human-microbial entanglements in the areas of policy, research and treatment. Finally, I conclude by arguing that fundamental elements of global AMR policy encounter unaccounted relationalities at the local level, rendering them nonscalable and putting at risk the fragile livelihoods of the local actors involved.

Emerging scales in assemblage ethnography

In my journey to follow AMR policies, I found myself constantly changing between emerging global and local scales that were enacted through vocabularies, documents and practices. In my own attempts to not lose my footing and fall myself into the trap of that scale game, making oversimplified assumptions regarding the identity of human-microbe relationalities, I started to think of my methodology in terms of constant travel, both physically and digitally, between the global and the local. To systematically approach this constant travel, I took inspiration from the notion of ‘assemblage ethnography’ (Youdell and McGimpsey 2015). Specifically designed to study rapidly changing policy issues by following policymaking and implementation networks, this type of ethnography allowed me to empirically explore complex policy implementation networks, paying attention to how scales emerge across institutional, research and more-than-human assemblages. This approach invites researchers to follow relevant actors – both human and non-human – by combining different methods and techniques. In the context of my study, this was particularly relevant because, in that constant travel, it often felt easy to lose track of what microbes are and the spaces they occupy.

Taking global AMR policy as a starting point, I followed its implementation all the way to West Africa, more specifically to Benin and Burkina Faso. These two countries have struggled more than most to develop and implement a national AMR action plan, given the lack of governmental and health infrastructure, and have thus become clear examples of the inequalities that characterise global health. Framing my methodology in terms of assemblages (Deleuze and Guattari 2006) carries several advantages. The notion of an assemblage allows me to highlight the hybrid characteristics of the more-than-human entanglements key to understanding AMR. Most importantly, the idea of an assemblage carries implications in thinking about the emerging character of those hybrid actors, their capabilities and multi-sited character, leaving us with a constant renegotiation of who is involved and a distributed understanding of agency.

To make sense of the more or less stable identity of these human and non-human actors, I rely on the notion of partial connection as formulated by Marylin Strathern (2004), which is useful when considering how the same objects are present in different contexts in ways that create similarity and divergence. Strathern argues that any comparison always entails some sort of partial connection, even if the comparison does not create equivalence between both objects within the comparison. The need to think in terms of partiality comes from the pitfall of representing the contexts we compare in terms of difference and uniqueness. In the case of microbes, analysed discussions of policy, research and care entailed working with understandings of microbes and resistance that are partially connected: that is, different and similar at the same time. The challenge lies in discussing connections between these contexts without representing them as unique or homogenous. This requires an understanding of the context that allows us to grasp the significance of the object, a framework useful for understanding the cultural and socio-political differences that feature in the implementation of global policy. Although we can agree on microbes as identifiers that emerge in policy, research and healthcare, their emergence does not take place in the same way. Sometimes they become relevant in one context because of their presence within another – that is, they become a global health policy concern before they become a concern within a national health policy or on an individual farm – rendering visible the hierarchical logic followed by global health. Similar dynamics occur with other nonscalable elements of AMR, which I will also address in this chapter. Thus, by understanding the different contexts and scales in which an object moves, we must acknowledge the constant shift in meaning, agency and identity. The microbe, the doctor, the farmer and the researcher are not understood in the same way within policy as they are within an academic setting or on a farm. The connections between one context and another are always partial, and the transplantation of different objects challenges their own significance and identity.

The research for this chapter relies on material gathered during two one-month ethnographic visits to Benin and Burkina Faso, complemented with documentary material. This includes the analysis of 38 policy documents from international organisations; seven policy documents from Benin and two from Burkina Faso; 27 semi-structured interviews with national policymakers, international collaborators, researchers and healthcare professionals; six focus groups with Beninese veterinarians and breeders; and two ethnographic diaries from fieldwork conducted in Benin and Burkina Faso. The fieldwork involved spending time in locations where AMR is shaped locally – that is, universities, laboratories, farms and hospitals. The following sections organise the insights gained during fieldwork around three central areas of AMR projects where scalability issues emerge: 1) policy development, 2) research and knowledge production, and 3) the diagnosis and treatment of bacterial infections in both humans and non-human animals. Examining more than one aspect of AMR helps to understand what makes such a project nonscalable across settings. Although I look at implementation in only two countries, by attending to practices of AMR across different, partially connected settings, I intend to provide a broad picture of the nonscalable elements that often feature in global health initiatives. Of particular relevance to this book’s perspective, this broad picture allows me to reflect on what nonscalability means for human-microbial engagements, an issue I return to at the end of each subsection and in the conclusions.

One Health and the antimicrobials that matter

In AMR discussions, One Health (OH) emerges as a fundamental aspect in defining the breadth of the AMR problem. OH is a public health approach that aims to recognise the links and dependencies between human and animal health, agricultural production and the environment. As I wandered the public offices of Benin and Burkina Faso, I found that policymakers from both countries relied on the notion of OH as their first frame of reference to explain the challenges embedded in combatting AMR. However, the fact that the term was ubiquitous and widely recognised did not mean that the core ideas and their practical implementation were understood unequivocally. The way in which the idea of OH is transplanted to specific localities is conditioned by the particular political practices and infrastructures that characterise each context.

This context specificity, and the relevance of local infrastructures, is something that characterises global health in general (Biehl 2016). Yet by incorporating OH, the issue is not only that global organisations operate with very different resources and mandates than their national counterparts, but also that differences emerge horizontally. The challenge here is not only one of making local contexts fit the OH rationale, but of moving elements across sectors that have traditionally worked in isolation, making clear that national contexts are not homogenous. Differences in budget, size, facilities and authority represented clear pitfalls to the development and implementation of a national policy that effectively considers AMR an issue extending beyond human health. My observations in the field are complemented with the analysis of both global and national policy, where OH appears to work more as a policymaking mantra than as an articulated proposal bringing relevant actors to the table to contribute complementary capabilities. Conversations with Beninese and Burkinabe policymakers provide examples of the nonscalability of the OH approach. While in conversations with human health authorities, conflicts between sectors hardly arose, in conversations with animal health stakeholders these difficulties were part of their everyday struggles with AMR, which manifested in the different cross-sectoral collaboration attempts that global policies demand.

In Burkina Faso, establishing an OH platform – one of the actions recommended by international policy – became a source of organisational conflict. Experts from sectors other than human health understood that the OH approach meant their contribution should be equally distributed. This was the position held by Dr Z, an advocate for animal health and agriculture, who asserted that before talking about AMR we must talk about the OH platform, which was, at the time of my visit, a work-in-progress. Although, in Dr Z’s view, the creation of this group represented an impressive step forward, other issues emerged, since the human health sector was reluctant to organise the platform in a horizontal manner. For human health stakeholders, OH is a human health issue rooted in International Health Regulations.1 In Dr Z’s view, this will not result in a true OH approach. Thus, Dr Z’s organisation promoted a co-leadership approach: they did not want the livestock sector to lead, but to find co-leadership alternatives. In Benin, on the other hand, approaching AMR as an OH issue meant reaffirming the status quo, with the human health sector taking the lead, while environment, agriculture and animal health played supporting roles. In my discussion with Dr Y, a researcher involved in AMR policymaking, it was explained that the absence of conflict between human and animal health resulted from the latter having been secondary to the process. Therefore, not everyone contributes equally to the process. These two positions provided different organisational understandings of resistant microbes. While in the first position resistant microbes remain an issue for the health of both humans and animals, in the second resistant microbes are portrayed as an issue in the animal context because of the effect they have on human health.

These two scenarios support the existing literature, which criticises the notion of OH because of its partisan focus. Hinchliffe (2015) has argued that OH makes one specific health – mostly human and mostly Western – stand for something much wider, through a reductionist process that denies the complex and multiple character of health. In the context of AMR policymaking, while OH attempts to conceptualise an interconnected understanding of health, such a formulation remains reductionist since it builds on a refusal to break with anthropocentric policymaking (Kamenshchikova et al. 2019). This anthropocentrism can produce infrastructural blocks for implementation, as in the first example, or prevent experts in non-human health from contributing on equal grounds to the development and implementation of national policy, as in the second example. These cross-sectoral dynamics might prevent concrete regulations from having their intended impact within practical domains such as farms, hospitals or the environment.

Scaling microbes, scaling research careers

One of the immediate consequences of the increase in global health policy to tackle AMR has been an increase in international funding for AMR research. In particular, an important investment has been directed at researchers in low- and middle-income countries, in the hope of boosting knowledge production in areas where concrete data about the presence of resistant microbes has been virtually non-existent. Some of these researchers, part of international consortia and projects to produce AMR data, were my first contacts with AMR circles in both countries. This gave me a privileged vantage point to understand the way local science production is embedded in a more or less scalable way into global policy initiatives. During my fieldwork, I met with a loosely organised, yet well-connected group of scientists that saw the new global concern about AMR as a key opportunity to boost their own professional careers. Their location in West Africa, defined as a hotspot that needs to be known by the international community through surveillance and data production, made the role of those scientists an indispensable one. However, local conditions for scientific knowledge production and the agency of West African researchers in the face of often totalising global health projects made sure the process of scaling back and forth between local and global was not without struggle.

One of the most evident ways in which local socio-material conditions got in the way of producing data that met the demands of global initiatives was the lack of laboratory capacity. Laboratories represent a valuable resource in West Africa, which cannot be taken for granted. All the laboratories I visited were under development and in need of equipment or unable to find the financial resources needed to update facilities established decades ago. Some of the latter had even turned into offices where dated devices for microbiological analysis accumulated dust. These facilities relied upon uncertain streams of funding from foreign organisations, funding which helped establish a laboratory despite the contextual constraints, and which remain invisible within global mandates for capacity building. Dr X, a microbiologist and postdoctoral researcher from a university laboratory, described the limitations imposed by this reality and explained how they were completely dependent upon grant applications to keep their laboratory updated. During my stay, Dr X’s laboratory needed a new molecular analysis section to isolate, identify and characterise bacterial strains using polymerase chain reaction (PCR). Without such developments, they were forced to rely on external collaborations for these types of analysis. Such limitations condition how microbes can be identified and how knowledge about microbes can be made scalable so as to enter the global arena. Furthermore, it limits local researchers’ autonomy to establish their own research agendas.

Researchers understood that an important part of their ability to contribute to international projects relied on the provision of data. To scale up their careers to become members of the international AMR expert community, they had to be able to turn locally taken samples into internationally relevant data, despite the precarious conditions of their laboratories, which complicated the gathering, conservation and analysis of samples. Success in that endeavour would help researchers carry out research that cannot be conducted in their home institutions. This would then also allow them to publish in more prestigious journals. In part, this desire represented a reaction to what they perceived as a non-rigorous means of building academic careers in West Africa, often based on publishing internally within their own faculty after little or no peer-review process. This contrasted with usual scientific standards in the global North, and so researchers with international ambitions insisted on differentiating themselves from local academic cultures that engaged in those non-rigorous practices. Yet these researchers continuously struggled to balance their criticism of local academic practices and their ability to work with global North scientific standards, which secured them funding through international collaboration, with their reluctance or inability entirely to abandon their idiosyncratic national or regional practices, thereby challenging the all-encompassing character of global health.

Traditional medicines served as strong candidates to build that identity, although they struggled to gain recognition for their medicinal value. African researchers dedicated time and effort to collect samples of herbal medicine that could be used to test their effect on microbial cultures. However, this part of their work was hardly recognised by their international collaborators. During conversations with European researchers, there was a tendency to dismiss the study of traditional medicines as non-rigorous or unscientific. Whilst antibiotics as a problem or a solution establish partial connections between local microbes and microbes addressed within global policies, traditional medicines become nonscalable since they challenge Western modes of knowledge production. Their role in regulating human-microbial engagements remained forcefully local. This provides an example of how, confronted with the unique entanglements that condition economic production, sanitation and hygiene, and a failure of development politics, there is a need to develop innovation and capacity in Africa consistent with local conditions and contexts (Louis, Nazemi, and Remer 2017). African researchers build a biotechnological-turned-biotraditional imaginary that encounters no counterpart in global policy. AMR policies provide a much less ambitious formulation, inviting experts to cherish existing antibiotics and to produce knowledge about the dynamics of resistance that develops around the globe, leaving out any emphasis on innovation. This understanding not only establishes various means of coexisting with microbes different to that which exists in the global North, but it also establishes specific modes of expertise not possible elsewhere. Thus, African researchers advocate for a chance to build their expertise around axes of native knowledge and responsibility towards a global mandate linked to the specific context in which they operate.

Access to laboratory and microbiological analysis tools is key in regulating how microbes can be known in local West African settings, but also how other local actors are able to interact and situate themselves on a global scale. Advanced testing and analytical methods require sending samples outside the region, transferring knowledge production to the global North. African scientists rely on those collaborations to understand microbes in ways that allow them to participate in international cutting-edge scientific discussions. Yet the specific context and the nonscalable nature of traditional medicines promotes a mode of microbe knowledge that stems from the lay use of medicinal plants, allowing for the creation of biotechnological imaginaries visibly missing in the global North. Both international collaborations and the use of traditional medicines help to articulate not only the scalability of microbiological science but the scalability of African microbiological researchers themselves as they struggle to become active partners in knowledge making.

Uncertain diagnoses, treatment and satisfaction

As mentioned in the introduction, a key aspect of global initiatives to tackle AMR is to reduce the use of antibiotics. The key strategy is to narrow their use to cases where a bacterial infection has been confirmed. This is another policy mandate that encounters serious difficulties in the studied areas. The difficulties of maintaining well-equipped laboratories, discussed in the previous section, extend here to human and animal health.2 Physicians and veterinarians rely on laboratories to confirm their clinical diagnoses, making specific infections visible and assisting in treatment decisions. However, the doctors, nurses, veterinarians and breeders I met confided that access to laboratory diagnoses was often prohibitive from an economic perspective or simply non-existent to those living in rural areas. Care professionals were forced to interact with microbes without what global health policy deems preferable – that is, a laboratory diagnosis. For example, while antibiograms (antibiotic-specific resistance tests for a given microbial colony) are available in West Africa and do not require significant laboratory investments, they are far from ubiquitous, typically only available in the largest cities and main hospitals. Thus, a rural veterinarian or physician who needs a diagnosis to make a treatment decision has little chance to send samples and receive results in a timely manner. The health of a patient or a group of animals might be at stake.

In these circumstances, both care for animals on farms and for humans in hospitals provide similar available paths of action related to bacterial infection, directed by individual and/or collective manifestations of resistance – that is, persistent symptoms that do not disappear after initiating treatment. Microbes, in such cases, form an assemblage with humans or animals and medicines, an assemblage interpreted through the lens of resistance. Often, no data or laboratory confirmations are available to indicate that the persistence of an infection is, in fact, caused by a resistant strain. Rather, this understanding is at times formulated as a suspicion which, given the lack of diagnostic capabilities, must be acted upon. A Beninese veterinarian explains that:

A diagnosis is not reliable [until] after the laboratory diagnosis. What we have in the field is a suspicion […]. We are obliged to limit ourselves to suspicion to advance the treatment, but theoretically we have been trained to make a diagnosis before treatment. In the field it is a little complicated because it is when the breeder has problems and there are mortalities, he calls you, and you must react urgently. Even if we have the tools we need, we don’t have the time to do the right thing properly before moving forward when the breeder wants to be satisfied.

With this lack of laboratory access and the added time pressure, often the conclusion that an infection is resistant is based on an unsuccessful antibiotic treatment. Successful treatment, on the other hand, is confirmed by the disappearance of symptoms and patient or breeder satisfaction with treatment. Otherwise, two possible paths of action are available in the case of failed treatment. First, treatment may involve increasing the dose; second, treatment can shift to a different antibiotic. These are, in the absence of laboratory confirmations and antibiograms, and given the impossibility of knowing the infectious agent at the microbiological level, blind steps from a scientific perspective. Alternatively, these steps also activate different modes of sensing that obligate veterinarians, breeders, animals, patients and physicians to communicate in ways that allow for resistance to become a part of the relational assemblage, productively compensating for the nonscalability of laboratory diagnoses.

In this relational setting, there is little space for guidelines that require a level of confirmation not available to any of the professionals encountered during fieldwork. In my conversations with Beninese veterinarians, the satisfaction of the breeder guides the veterinarian’s decision-making. In the case of human health, the satisfaction of the patient dictates the persistence of the infection, as explained by the managing director of a Beninese district hospital:

Yes, that’s the problem: how do I know if the patient is not satisfied? Because, generally, when you start the treatment, you have to feel better […]. When the patient returns and you notice that the parameters have not fundamentally changed, as a doctor, the first reflex that you have is to change the product and maybe prescribe a higher dose […]. You may not know. So, all you can do is just change the product, hoping the second one is better.

In the absence of bacterial infection diagnostic testing, an interaction with other microorganisms and diseases like malaria creates an even more complicated assemblage. The international push to develop treatments for malaria, together with efforts by nongovernmental organisations, have ensured that even in many remote rural areas malaria rapid tests are accessible. However, confronted with symptoms of a fever and a negative malaria test, bacterial infection becomes the immediate diagnosis in the absence of testing, followed by the subsequent prescription of antibiotics without a laboratory confirmation.3

What remains nonscalable here are general recommendations to reduce antibiotic use in humans and specific statements to not use antimicrobials of critical importance to humans when treating food-producing animals (World Health Organization 2017). These recommendations represent an important element in the behavioural understanding of AMR (Pearson and Chandler 2019). Policy implementation in the field confronts a more collective relationality that challenges the individuality of behaviourism, an approach that becomes a nonscalable element in its clash with local specificities. Similarly, reducing antibiotic use through diagnoses is in this case a difficult if not impossible task. This is particularly true in rural areas, where often only nurses or pharmacists are available to provide any medical advice, or where an unaffordable hospital trip means losing a day’s wage. For animals, calling in a veterinarian can represent a prohibitive service for a breeder, putting the economic viability of their farm at risk, and an action usually reserved for only the direst situations. Until then, they rely on advice from family and friends with whom the constant exchange of information and experience remain crucial to producing collective modes of diagnosis.

This supports Denyer Willis and Chandler’s (2019) claim that understanding the role of antibiotics links with how entrenched they are within a society. In the case of farming, various antibiotic uses associate with financial needs. Thus, the notions of use, misuse and even lack of use become complex in the economic and productivity networks of humans, animals and microbes whereby antibiotics become generative of either health or disease. This also agrees with studies demonstrating a pragmatism in antibiotic prescription connected to the conditions of access to diagnostics (Pearson and Chandler 2019). Indeed, in my material, farmers’ and patients’ use of antibiotics connects to pressing needs, given the lack of affordable alternatives.


In this chapter, I have illustrated some elements of the scalar difficulties of implementing AMR policy in two national settings: Benin and Burkina Faso. I argue that fundamental elements of global AMR policy encounter unaccounted relationalities at the local level, rendering them nonscalable. Still, many of those elements manage to retain their identity as global health objects despite their varying ways of being established by each specific local context. Similarly, elements of everyday life with microbes in these contexts, such as the use of natural medicines or collective modes of diagnosis, cannot be harmonised with global health policymaking and Western modes of knowledge production. My fieldwork shows that microbes emerge differently together with the diverse scales that global assemblages produce. The scalability or nonscalability of different elements plays an important role in the regulation and coexistence of humans and microbes. Based on examples in which humans, animals and microbes materially coexist, similar to ‘living with malaria’ (Beisel and Boëte 2013: 126), there is a need to live within human-microbial entanglements. These entanglements inevitably involve the dynamics of resistance often mediated by non-human animals, the environment, and medical, scientific and governmental tools. Thus, in a way, within the contexts examined here, there is a need to live with resistance. The specific shapes that coexistence takes are mediated by practices allowed by the infrastructure.

The lack of resources necessary to produce systematic knowledge that allows local communities to understand their microbial neighbours from a microbiological perspective pushes care practices towards relational modes of knowing that are often not compatible with the regulatory modes offered by global health initiatives. Similarly, the immediacy of the economic risks entailed by disease represents a crucial factor that keeps small breeders from developing practices to avoid situations where AMR may kill up to ten million people annually by 2050 (O’Neill 2016). While economic security remains an unattainable asset at present, it is hard to put that security on hold for the sake of a distant future which is unknown to many stakeholders. Living with resistance is an ironic correlate to living without data, data that could potentially provide evidence of resistance as a genuine phenomenon. From a global health policy perspective, living with resistance seems to represent a corollary of living without combinations: living without surveillance, living without laboratories, living without confirmation, living without resources. Given this perspective, I propose that living with resistance is also the result of living with global policy that fails to consider local relationalities, rendering AMR policy nonscalable.


1 IHR is a legally binding framework aimed at regulating health internationally, involving WHO members. This ambitious venture began with its publication in 2005 yet continues to struggle with implementation (Burci and Quirin 2018).

2 While human and animal treatments of bacterial infections involve obvious differences, here I present examples from both, since achieving a diagnosis is similarly difficult in both humans and animals. Furthermore, this agrees with the more-than-human concerns (Whatmore 2006) underpinning this chapter and the entire volume.

3 Efforts exist aimed at developing rapid tests for bacterial infections (Narang et al. 2018), which have been found to occasionally decrease the unnecessary use of antibiotics (Do et al. 2016). But they are far from ubiquitous and none of the informants discussed them.


I would like to thank my anonymous informants in Benin and Burkina Faso for their time and guidance, all of the attendees to the Kilpisjärvi workshop for their insightful comments, the Kone Foundation and the Academy of Finland for their financial support of this project, and Vanessa Fuller (Language Services at the University of Helsinki) for assistance with the language revision of this manuscript.


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