World without Antibiotics

We’re on summer break until Labor Day. In the meantime, please enjoy a day-by-day countdown of some of our most-read articles since last summer. Today, #6, originally published on November 13, 2017.
Sepsis: a systemic response to infection. The body gone wild. A reaction disproportionate to its cause, one that refuses to respect the division between ...

“I thought, what would be the biggest obstacle you could throw at a surgeon? Taking the tool of antibiotics away from them.”

—Sara Kenney


Sepsis: a systemic response to infection. The body gone wild. A reaction disproportionate to its cause, one that refuses to respect the division between hearts and limbs. Diagnosing sepsis requires a sense of proper proportions. And in Surgeon X, a comic series about a world in which antibiotics are facing their last stand, it becomes piercingly clear that proportions of all sorts—ethical, political, biological—have gone out of whack.

Surgeon X unfolds for the most part across London, in the year 2036, only a heartbeat from where we stand today. When speculative fiction leaps far into the future, we’re often stranded in worlds that are post-apocalyptic or dystopian. All of the really serious decisions, for better or worse, have already been made. The much shorter hop into the near future forces us to reckon with decisions in the making. While the consequences of our present actions in the world are still becoming clear, we have yet room to maneuver.

In the proximate world of Surgeon X, antibiotic resistance is spreading, the people of London mill around the streets wearing masks, and a politics of triage is taking hold. In this world, access to antibiotics depends on the Productivity Contribution Index (PCI), a score that reveals how worthy you are of salvation. If you are overweight or elderly, you might be denied antibiotics. If you have exceeded your rationing limit, you can’t have more. The right-leaning Lionheart Party, which rules the city in the wake of a political assassination, sums it up rather nicely: “Rationing is Rational.”

But this slogan, like all political catchphrases, necessarily leaves much unsaid. Rationing is, above all, about establishing proper proportions. In a sense, rationing provides a counterweight to sepsis, an orchestrated distribution that stands against a freewheeling metastasis. The question of how medicine should be apportioned—what kind and how much for whom—provides the ethical substrate underpinning the decisions that have yet to be made in Surgeon X.

Yet, as the story progresses, we find that determining the proper proportion is no easy task. At first glance, the Lionheart Party, which routinely demonizes war and climate refugees, is easy to dismiss as the fascist antagonist of the story. While the head of the party warns of “antibiotic apocalypse,” his more sympathetic rival worries about “denying vulnerable people antibiotics.” Yet, all proportioning—whether in the form of triage, rationing, or all-out eugenics—requires some form of denial. Eden has been forever lost. The original affluent society in which desire and supply meet harmoniously survives only as an anthropological memory. Perhaps not so different from our own world, the world of Surgeon X is one of limited means.

We find a grim reminder of this in a hallway of a hospital featured in the first issue: “Wash your hands or risk losing your limbs.” With the restriction of therapeutic means, prevention takes on an almost threatening aspect. Lest we find such macabre warnings extreme, we might do well to remember the kinds of graphic images that have come to feature prominently on cigarette packs over the past decade or so.

“The idea is to really think about what this world could look like, what state we could be in, in terms of the antibiotic crisis,” Sara Kenney, the creator and writer of Surgeon X, told me in April. “I like to think of it as a thought experiment. What if we don’t manage to find new antibiotics, what if we don’t have the political or financial will to solve this crisis? How bad could it get?” Kenney is no stranger to weaving fictional worlds out of the threads of grizzly realities, having worked on the BBC’s Casualty, the longest-running prime-time medical drama on television. I asked Kenney about the genesis of the ads that appear in her series.

In constructing this London of the near future, Kenney told me that she asked herself: “What would be the public health message of a far-right government?” Influenced by Russian propaganda and Bauhaus, Kenney collaborated with the designer Simon Armstrong of the creative studio ticktockrobot to envision a series of print and video pieces about antibiotic resistance. “There’s no gentle persuasion,” Kenney said. “We wanted to create this sort of fierce public health campaign.” Alongside these ads, Kenney began to envision the kinds of products that might be sold by people “capitalizing on a crisis,” like cleaning robots and bactericidal sprays. In the world of Surgeon X, the threat of contagion seems to work both to inspire healthy behavior and to move product.

To help navigate this world, we are provided with a rather unsteady guide in the form of Rosa, a surgeon who works as part of the National Health Service. “She’s not your typical hero,” explained Kenney. “I wanted to play the ethics of the situation, and really sort of show her move from being a darling of the National Health Service to a character who will judge, and who you will judge.”

And in fact, Rosa’s judgment—clinical as well as ethical—is repeatedly put to the test from the first pages of the story. “In Rosa’s head, the way that she is operating is for the good of society. A lot of the stuff that she does—arguably it is to improve the conditions for the people who don’t have access to the drugs,” said Kenney. “It’s quite easy to see how she could justify that.”

The sympathetic aspect of Rosa is on display early on in the series, when she encounters Madison Smith, a young girl who requires the removal of her kidneys after surviving an explosion at St. Pancras Station. Hospital management describes Madison as “a high risk for an infection, disabled and obese”—and potentially ineligible for further antibiotics. Over the past half century, antibiotics have become foundational to much of biomedicine, from surgery to chemotherapy. Without these drugs, which are kept under strict lock and key at the hospital where Rosa works, dialysis and organ transplants are potentially lethal.

The kind of therapy available in the world envisioned by Kenney begins to look an awful lot like battlefield medicine.

The consequences of being a bad subject—one who can’t, or doesn’t, take care of themselves in ways that are sanctioned as healthy—are dire. Madison’s parents shrug when told they need to reduce her PCI score. “Processed food is cheaper,” her father explains, “and I read that it’s safer.” Although Rosa upbraids Madison’s parents, she promises to help them and secures a bioengineered kidney for Madison from Korean scientists on the dark web. In this world of the near future, the fading glow of heavily regulated antibiotics has been replaced by the shiny new promises of regenerative medicine, remote-controlled surgical robots, and online shopping.

Of course, there are other ways of being a bad subject. Lola, a friend of Rosa’s brother, is injured in a hit-and-run accident. As an undocumented immigrant from Russia, she is terrified to go to the hospital. And it doesn’t help that she’s loaded up on party drugs. And then there’s Lola’s girlfriend, Mai, who strays from the presumed safety of monogamy and comes down with a case of super gonorrhea. To make matters worse, she’s already exceeded her antibiotic ration.

In these cases, Rosa refuses to submit to the judgment of a bureaucratized medicine. Instead, she hastily assembles a clandestine operating theater in her basement, unburdened and unbound by hospital regulation and political will. There, she performs amputations and excises necrotic tissue, removes limbs to salvage lives. There, she dispenses antibiotics and experimental treatments that she procures from the black market. There, she develops her own ethics, refusing both the oath-bound morality represented by a holographic Hippocrates and the rationalizing ethics of the Lionheart Party. Ultimately, however, a surgical scalpel is a blade like any other. Taking for herself the power of the state, Rosa will decide who lives and who dies—and fair warning, not all will survive her judgment.

In portioning out life and death, Rosa must also bear the consequences of her decisions. “I think she is making judgments that are ethically dubious,” Kenney told me. “I wanted her to be somebody you would agree with sometimes, and then think she’s being a massive unethical idiot at other times.” Yet, after finishing the six issues that compose the first volume of the series, I was left wondering whether there were any ethically pure decisions available to make. Isn’t there always a cost? If we fault Rosa as an “unethical idiot,” is it really for making the wrong choices, or rather, is it for failing to recognize that there is inevitably a price to be paid?

I asked Kenney whether she thought that the history of medicine—of Nuremberg, Tuskegee, and the many other highly visible episodes of bioethical reflection—provided us with a kind of compass. Or is antibiotic resistance so different, I wondered, that this history offered inadequate guidance, for us, and for Rosa?

I do think that it’s very different. This is probably why doctors are going to struggle. When you have your patient in front of you who is poorly, and you have to act in their best interest, and you don’t know whether they have a bacterial infection or a viral infection, your instinct presumably is going to be to give antibiotics. But where’s that line where you say, “I need to think about future generations, but I have this person sitting in front of me?”

In Kenney’s view, the question of rationing or triage—of how to apportion a limited good—is not only about who should and who shouldn’t get antibiotics in the present. It is also about a potential trade-off between lives that can be saved now and lives that can be saved in the future.

This delicate and perhaps impossible balancing of present and future weighs heavily on the question of how to distribute what are often referred to as drugs of last resort. As a medical anthropologist, I’ve been trying to understand what it means to be cured through a study of tuberculosis treatment in historical and present-day India. One part of the story that I’m trying to tell deals with the spread of drug resistance and the rationing of the newest anti-tuberculosis drugs in India. In both obvious and surprising ways, this story of India’s past and present resonate with Kenney’s adroitly painted near future:

If you’ve got this sort of line of last resort … when do you use it? Does it have to be [just] life or death situations or [otherwise] you’ll just have to get by? Is it acceptable to have to live with a urinary tract infection that might make you very uncomfortable, but it’s not going to kill you? Is it acceptable to have an amputation if you’re going to live? Do we save [antibiotics of last resort] just for people who are literally on death’s door?

In fact, in the London of Surgeon X, India plays an important part, both as a supplier of bootleg antibiotics and a reservoir of drug-resistant infection.

I wanted to explore black market pharmaceuticals and the role that they would play in an antibiotic crisis … so I started thinking: how on earth could you stop this in a situation in which people are desperate to get antibiotics even if they’re not working properly … where a government has decided that you can’t have antibiotics because you don’t qualify—not based on medical need, but because you’re being judged on your background, because you have disabilities, because you’re an immigrant, because you’re too old so you’re not benefitting society anymore? You’re inevitably going to have a growth in the black market.

Unable to access antibiotics for her underground operating theater through legal means, Rosa turns to other sources. She begins making regular visits to an Indian restaurant run by Priya and her brother Vikram. This restaurant operates as a front for an antibiotic smuggling ring, founded by Ravi “the Vial” Varma, the grandfather of Priya and Vikram. In his younger days, Varma was a notorious drug smuggler. Now, as an old man, he has been stricken by a highly drug-resistant strain of tuberculosis after a series of erroneous treatments. In considering the relationship of India (and Indians) to this antibiotic crisis, Priya puts it simply: “Yes, people are dying here, but in India it’s fucking carnage. TB, Cholera, Super-MRSA. Yet we continue to serve the West because we’re desperate.”
The septic world of Surgeon X is one in which drugs flow uneasily along arteries connecting India to England, producing, yet again, a sense of disproportion. “Not everyone around the globe has the NHS, has this access to medicine,” Kenney told me. “Medical advancement is extraordinary … [but] we haven’t solved politically, financially, ethically, how we make this available to people.” We need to consider, she insisted, “how this advancement in science is probably driving the chasm between the rich and the poor.”

Rather than sealing rifts, progress seems predictably to embolden preexisting fractures across lines of geography, race, class, and gender. In the London of Surgeon X, there are more than a hundred amputations a week, pharmacies are robbed for vital medications, and the poor use second-hand prosthetics that don’t quite fit. The kind of therapy available in the world envisioned by Kenney begins to look an awful lot like battlefield medicine, in which limited time and resources require salvage operations to prevent the loss of limbs or life, but not always both.

Scholars who study science as an eminently social phenomenon will recognize in Kenney’s series a familiar critique of technology as both deterministic and salvational. “What I wanted to do with Surgeon X is to really make people think about medicine not just in the terms of the whiggish ‘isn’t science amazing, look at what medicine has done,’ but also think about how it drives inequality,” Kenney explained.

I could see the situation where we slip into an unjust rationing, where decisions are made whether you’re worthy of this drug, whether you’re contributing. Or even health-wise, if you’re a smoker and you get a chest infection perhaps people will say it’s your fault, you shouldn’t have smoked—but smoking is hugely linked to things like poverty and mental health, so you can say, is that really a fair way to go? … But I could see certain regimes in which it is something that would be considered. That’s why we need to ask these questions now, because it hasn’t happened yet, and we’re not quite down that dark road yet, but I think we need to think about the road that we’re traveling on. …

When we have advancements in cancer treatments, advancements in prosthetics, how will we decide who will get access to these treatments? Already, there are people who aren’t getting access to these life-saving treatments because of a post-code lottery, or because you can’t afford them in certain countries.

In Surgeon X, the problem of proper proportion seems unavoidable. The question that remains is who will decide and how. As our therapeutic options continue to dwindle, we might be forced, like Rosa, to make ugly choices. But rather than assuming that the choice is between a fascist triage and morally upright abundance, Surgeon X encourages us to carefully consider the price to be paid for different kinds of proportion. “I think the questions that we’re exploring in terms of antibiotic resistance could help us in terms of how we think about medicine as a whole,” Kenney told me. “I don’t have answers. I just have a lot of questions.” icon

All images displayed above are from Surgeon X: The Path of Most Resistance, written by Sara Kenney and illustrated by John Watkiss.