Hello, and welcome to this talk about antimicrobial resistance and stigmatization. In the first part of the talk, I'll be discussing stigmatization more generally and then move on to talk about dynamics of stigmatization in the context of AMR. What is stigmatization? In ancient Greece, stigma refer to a mark branding the buddy to indicate the lesser status of slaves, criminals, or people who were otherwise considered less worthy and morally unfit for participation in everyday sociality on earth with Greek citizens. To stigmatize is to lamely another person or an entire group of people as unworthy of social recognition. Put simply, stigmatization is a particular social relation of rejection. It ranges from microprocessors in everyday life to structural forces in society. It may be part of the moral fabric that punishes what is considered as deviance, in a given context with social sanctions. But at institutional and structural levels, stigmatization can be used to justify discrimination and suppression and can be politically invested with suppressive ideology and military force. It is in particular relation in the sense that it requires a clear distinction between an I or we and another. This process of othering establishes a moral hierarchy between the two. That it enables the I to assign blame to the other. This difference between I and other is then exaggerated in order to overshadow human commonalities that would otherwise justify equality. In this way, the concept of stigmatization points to this symbolic extension of the particular difference to colonize the entire identity of the stigmatized. Disability matters is the mark of differences visible, it is readily identified by the stigmatizer, this is saying that the other person is a potential target for stigmatization. Post-colonial history attests to the overwhelming use of racial difference as such a mark to legitimize exploitation and privilege. However, the wide range of visible features may be subject to stigmatization. People with physical handicap may be required to anticipate and routinely tried to prevent stigmatizing situations when interacting with strangers. Gabriel, have been disfigured by untreated left PRA, may provoke the instant fear in others, leading to rejection and expulsion. In his classic work on stigma-driven, Goffman made a distinction between the discredited having a visible stigma and the discreditable who were at risk of becoming stigmatized. If the stigma was discovered. If Malcolm potential stigmatization is not visible. The strategy of the discreditable becomes fun of information management. This was very clear when the eighth pandemic began to spread in the 1880s until the combination treatment became accessible. The stigmatization and victim-blaming of people infected with HIV worked as it is incentive to become tested. In this way, stigmatization has the potential of driving an epidemic thundercloud. They found positive manifold and need to manage this information very carefully. Avoiding being seen at eight clinics or otherwise be associated with the disease. In order to avoid or reduce stigmatization, these activists have continuously for to destigmatize the disease through awareness campaigns and other activities. Several points can be drawn from this so far. First, the perceived nature of the market itself matters for the risk of stigmatization, and the format may take it may be inherited or occur later in life involving varying degrees of agency and may be temporal or permanent. It may be assigned to the individual on entire group. Varying forms of difference may be linked differently to norms of morality, guilt, normativity, and decrease of intolerance. Values of diversity versus uniformity. Consequences for the target may range from momentary frustration to general withdrawal from social life, and even life-threatening situations. Second, multiple characteristics may be used to reinforce stigma. As was seen in the layered stigmatizing of aids and minorities such as Haitians in the US. In other words, stigmatization when layered tends to operate along existing fault lines of power and inequity. I now move to the issue of antimicrobial resistance and stigmatization. From a biomedical perspective, antimicrobial resistance arises as microorganisms respond to the presence of medicines such as antibiotics. This process places the human host at risk of resistant infections. But at the same time, the host becomes a reservoir of dangerous contagion. From a biopsychosocial perspective, the dynamics between the I and the other cellular level is transformed into an I and a potential potentially dangerous other at the human scale. Using three rather different examples, I'll discuss AMR stigmatization in relation to dynamics of fear of the ring and blame. AMR and fear. In Denmark, Methicillin-resistant Staphylococcus Aureus, or MRSA, has spread in connection with use of antibiotics in pig farming. The study of Danish pig farmers' experiences of stigmatization pointed to the unintended consequences of the hybrid medical and public focus on MRSA. Well as control measures for biomedical justified, farmers experienced a spillover of the fear of MRSA in their everyday lives. This affected their children who are no longer invited for birthday parties and then daycare centers other parents demanded special measures to protect their children from infection. This conflict could be managed within the institutional framework, but informal social regulation outside the institution and world risk of social exclusion. This was also clear from a handbill that was distributed in a local area with many pig farms. It read MRSA CC398 is extremely contagious and there's no cure for people working on pig farms. If you work on a pig farm, you should refrain from having sex with others or seeing anybody or not themselves infected with MRSA. In this case, stigmatization is driven by fear and may be considered a deliberate tool to protect community members outside pig farming from risk of MRSA infection. The farmers on their part felt that their efforts to limit the use of antibiotics did not reduce stigmatization. Transmission of infectious disease is itself a form of bias social and communication and increased mobility and travel between groups of humans increase the risk of such transmission. This is true irrespective of AMR, and therefore also true for travel of microorganisms with AMR. According to a Dutch study, this has spurred an interest among microbiologists in the Netherlands to initiate screening of non-hospitalized healthy refugees for AMR. However, refugees constituted a group that was already subject to stigmatization and singling out refugees rather than, for example, tourists as a target for a mass screening involved the risks that they were held responsible for disseminating resistant bacteria to host countries and imposing danger upon other people. When AMR screaming is seen outside of the social and political contexts, its stigmatizing dynamics can easily be overlooked. Scene out of context, understanding the moving of AMR across different parts of the world is scientifically interesting and potentially important. However, using refugees to this effect without appropriate attention to prevention of stigmatizing dynamics spurred by the screening is problematic. As the study showed, refugees would appreciate information about potential risks of overuse of antibiotics, which was common where they came from. They would also expect some personal health benefits from participating in the study. For example, the cases of AMR were treated. However, from a biomedical perspective, this would not normally be considered necessary in otherwise healthy individuals. AMR, stigma, and blame. The third example is based on my own research in India and concerns assigning blame in the context of treatment for multi-drug-resistant tuberculosis. I just keep sections of the quote, but you may pause the video if you want to read the full excerpt. Batuk was 19 and in tenth grade when diagnosed with TB. Living in poverty in a 'basti' in a large city, he was the best-educated member of his family. Relative delivered the medicines and left without checking if he actually took them. At first, Batuk took these medicines. But he had not been informed of the implications of interrupted treatment, and so he's stopped taking the medicines when he began to feel better. Around four months had passed without medicine when he started coughing blood. When he went to hospital, he was severely reprimanded and labeled a 'defaulter'. At this point, Batuk was diagnosed with drug-resistant tuberculosis, and the doctor made sure to write 'chronic defaulter' on his file. At this point in time, Batuk's daughter had just been born and Batuk's motivation for tuberculosis treatment was high, despite the severe side effects caused and the additional burden it imposed on his poor household. The years that followed were a continuous fight to be deemed worthy of treatment despite the label of 'chronic defaulter'. The fight ended when he died from extensively drug-resistant tuberculosis in October 2020. Tuberculosis is a stigmatized condition on its own due to the fear of contagion and the scary image of coughing blood and dramatic weight loss. But when proving to be difficult to treat because of drug resistance, the fear may increase along with stigmatization. However, Batuk's case shows that being blamed for development of drug resistance, and being labeled as a chronic defaulter made his subsequent treatment much more difficult. In Batuk's body, new forms of resistance developed to an increasing number of anti-TB drugs over time, rendering all of them ineffective. There's no way of knowing whether Batuk could eventually have been cured, had this mark not been put on his file. But it is safe to say that it did not increase his chances. Fear, othering, and blame are the main drivers of stigmatization and they go together even if the three cases here have served to highlight one dimension over the other, as I've described, AMR can lead to stigmatization on its own. As in the farmer's case, what can be multilayered adding to existing stigmatization. For example, when screening healthy refugees for AMR without considering the wide identifications. Stigmatization can be as militating on its own as any disease that may trigger it. Furthermore, it has the potential of driving infectious and pandemics underground, including those that involve antimicrobial resistance. Successful interventions to prevent, reduce, or eliminate stigmatization can, by contrast, improve access to appropriate prevention and treatment of AMR. However, such interventions should consider the multilayered nature of stigmatization, and how broader patterns of inequity and discrimination can increase risk of development and transmission of AMR. Thank you for your attention.
