SHE Pod Season 3 Episode 3: Diego Silva and Kari Pahlman on Ethical Health Security and Antimicrobial Resistance

1:21AM Apr 28, 2022

Speakers:

Kathryn MacKay

Diego Silva

Kari Pahlman

Keywords:

security

rivalry

paper

health

guess

kari

values

antimicrobial resistance

antibiotic

antimicrobials

findings

bioethics

deplete

public health

referred

anti

australia

public

terms

political science

Hello, and welcome to the SHE Research Podcast. I'm your host Kate McKay. And today I'm joined by Kari Pahlman and Diego Silva to discuss their paper co authored with Anson Fehross and Greg Fox, 'Ethical Health Security in the Age of Antimicrobial Resistance'. Welcome, Kari and Diego.

Hi, thank you.

You're welcome. Thanks for joining me. This is a super interesting paper given the times, and I wondered if you could give us a kind of elevator pitch of what your paper is about?

Sure. So I guess the paper is premised, it's based around the way in which antimicrobial resistance or AMR is, you know, frequently referred to as a threat to health security. And we see this kind of in Australia's health security language, but also kind of in wider context around the world WHO, or the World Health Organisation elsewhere kind of refer to it, you know, as a threat to health security. So, at the same time, we also, you know, because of the potential kind of obsolescence of antimicrobials, I suppose, the preservation of antimicrobials, or what we found referred to in the papers as AME, antimicrobial effectiveness is often described as a public good. So how the term public good however it is not... and the values I guess, that underpin it are not always well understood or well articulated in kind of in kind of this health security language. And so this was the main objective we wanted to really understand the notion of public good, how it's used in these contexts, and also understand, I guess, the underlying values that kind of justify that approach. Yeah.

Okay. I want to come back to those values in a second. But first, I have a question for you. Which is, I wonder if you can say, maybe just a little bit of something for the listeners about the difference or the connection between public health and health security?

Yeah. So hi.

(laughs) hi Diego.

Yes, so I think that when we're talking about health security, we're referring to something that's a contested term. And so and I'm not just saying that political scientists who actually do this stuff are saying that. It is a term that refers to essentially the securitisation of something in this case, health, and what that means is that you're trying to protect x in present for some future.

Okay.

So it might be borders, right? It might be the integrity of your economic system, whatever the case might be. In this case, we're talking about the health of a population. And so what you're trying to do is set up parameters so that you're, you're actually trying to give some kind of assurance that there will be health for population in the future. It's very, very politicised as an idea. But I would say generally, that's kind of what we're talking about, at least that's how I understand it. Kari can can can speak to this as well. Public Health on the other hand, I think we were more familiar with. I really like Marcel Varvases and Dawson's understanding of public health, being public insofar as you're looking at population, but also public in terms of the collaborative efforts that you need to ensure health of the population. So I think there's an overlap there, right, when we're talking about ensuring health for future. But I think that... more than the definitional difference, what we're looking at is an operational difference. So whereas public health is something that falls within the remit of the states, here in Australia, for example, when we talk about local public health units, health security tends to be at a federal level at a national level, not exclusively by any means. We speak of health security, in context of regional international, oftentimes has to do with borders and health. So even though kind of the definitions, I would say are kind of fuzzy, in a sense, there's I would say, in practice, again, pointing to Kari, you can sort of chime in, there's actually sort of a division of labour, or at least a division of perspective.

That's helpful. Kari, did you want to add? No, okay.

That sounds, about it.

Your background is in political science. Is that right?

Yeah.Of sorts.

Yeah. So were you working on health security before this?

In my master's, I was looking at kind of the pre migration, tuberculosis screening requirements in Australia as that was kind of my main thesis in my master's but before that, it was more actually Sociology, Anthropology of health, that kind of thing and Political Science. Yeah.

So what got you interested in writing a paper on AMR? What were the motivations for writing this one?

Apart from getting a grant?

(laughs)

So, so I think we have maybe slightly different motivations, I'll tell you my motivation. And then I think there was a sort of an alignment of interest in, which is why I kind of went to Kari to help me work on this. So when I arrived in Australia, back in July 2019, I noticed that there was a lot of discussion of health security within public health. And within the, within the discourse around infectious diseases in a way that actually hadn't seen back in Canada, or when I was in Germany or something like that. I thought it was really curious, I just started to dig a little bit, and there's this, there's a much greater alli-, coming together of infectious disease and security here, then I would say there is in Canada. This is my impression, it might not actually be the case but it's certainly my impression. And so it just got me thinking, Okay, what do we mean by these terms? So the defat, you know, talks about AMR, in particular, being a public good. What does that even mean? So that was kind of the genesis for me. So I don't know in terms of motivation. Yeah.

Yeah. I mean, I think that this is, you know, since starting my PhD, this is kind of my first real, I guess, dive into into bioethics and kind of the value side of things and the kind of the moral deliberation of these issues. So yeah, that was definitely a motivation for me as well to kind of tie that health security kind of political science aspect that I'd studied a little bit before. And kind of bridge that with, yeah, the kind of the bioethics space.

Yeah, that's really interesting. I find it fascinating. And I want to know more about how Australia's kind of political landscape and public health landscape means that health security comes together more with public health, and maybe in other places, I find that really interesting. So, I mean, that leads me to ask you what some of the findings were from this this paper, you mentioned at the beginning that there was some values that you picked up on, and a lot of discussion of antimicrobials as public goods. And I think you mentioned in the paper that some there's some slippage between public goods and common goods. So yeah, I wonder if you could just say something about the values that you found and, and how they're playing out in this place?

Yeah, so I guess we had two, two main findings and conclusions. The first being that yeah, we wanted to kind of see how how health security or in the context of antimicrobial resistance was kind of understood, or used as a public good. And from there, we found that yeah, there is actually at times, maybe a confusion or lack of clarity, conceptual clarity as to whether it's, it's a public good or common good, because there were, I suppose it was used interchangeably at times, or at least without clarification. Public Good, I guess, from the macro economic perspective being something that's not exclusive. So you can't exclude anyone from from sharing in its benefit and also non rival in the sense that one person's use of the good doesn't kind of diminish the availability of that good for the next person. Common Good differentiates in the sense that it is rival. So by definition, it's saying, well, just like, you know, I guess this is often used in terms of the tragedy of the commons is where it's often referred to, but so say one person fishing in the sea is going to reduce the number of fish in the sea for the next person. So in that sense, you know, the argument goes, that one person, you know, using anti microbials, or taking antibiotics would reduce the effectiveness of antibiotics for other people or that same person into the future. So that was kind of the first finding. And I don't know if you want to speak about the conclusions of or , like the, you know, how we drew from that the conclusion being, you know, the role of rivalry in the senses is a normative one. We, our argument was that, you know, it's not a dimension of the good in and of itself, whether it's rivalry, it's more, that's something that's imbued by the kind of social and environmental context in which it exists, I suppose.

Yeah, so I think just to pick up on on what Kari was saying. So I think, you know, we were looking at the use of certain words and values like justice and protection from harm and these sorts of ideas, solidarity. Some papers went into more depth than others, but particularly on this sort of common good public good. I think one of the conclusions we drew is that the discussion tended to look at this as a fait accompli that we were going to develop antibiotics in the manner and in the market system that we currently have, but I think one of the, for us as we were having discussions around the paper was, well, why why does it need to be like that? So that this notion of rivalry, again to pick up on something Kari said, depletion is different than rivalry, right? A stock can deplete at least temporarily, or, but it doesn't necessarily mean that rivalry is baked into the good itself, it can be a product of a system, which we've created. And so I think that was one of the that was I guess the second conclusion is to say, Well, wait a second, can we think differently about that? And more importantly, I guess, is, or not more importantly, but as importantly, is this idea that I think part of the reason that we're having this failure of imagination is because we're not being clear about the values, because we are using, because it's almost ships crossing in the night. So people taking different perspectives, whether it's more globalist whether it's more regional and more sort of insular, people are speaking from different... they're, they're starting from different assumptions. And until we get clear on those assumptions, and those the values that underpin those assumptions, then I think we're just going to keep talking at cross purposes when it comes to antimicrobial resistance and when it comes to anti microbial effectiveness.

Can I ask... maybe it's just a really basic question, then. Aren't anti microbials rival by nature?

Yeah.

(laughs)

So I think that there's a way in which they certainly can deplete.

Okay.

Right.

Okay.

So and it's certainly true that the actual vial of say an antibiotic that you're given can't physically be also the same antibiotic. But this idea of that we, that we are in a position where, say, we're up against low... Australia, high income countries up against low income countries and their misuse or their, you know, empiric use of of a diet... you know, a particular antibiotic because they don't have the testing blah blah... So that's the manmade rivalry part.

Oh, I see.

So there's so it's, it's not it's, it's not a it's not that it's the, you know, the quintessential example we give in the paper is the streetlight, right? Your enjoyment doesn't negate in any way my enjoyment of it, but streetlights do deplete. Right. So, so I think for us, it was separating the idea of depletion from rivalry and the the sense that rivalry can be used, and is used implicitly in a normative sense in this in this value laden sense.

Yeah. And that, I guess, the other thing that we use to exemplify that is that it's probably more a market based conceptualization, and it's in this free market paradigm where rivalry becomes the distinguishing factor or the the condition in which makes anti microbials perhaps deplete faster than they otherwise would, you know, there's there's nothing, what we argue is there's nothing to say, well, we couldn't imagine, perhaps a different scenario or a different kind of if we reimagine the way in which we steward antimicrobials, and steward kind of that more judicious use of how we go about that, that we couldn't see a scenario where perhaps we have, you know, a scenario where we don't have we don't aren't able to conserve microbials for for use in the future, or at least not deplete them faster than you know, we are also developing new ones, for example.

Right. Yeah, that's really helpful.

I don't know if that was very articulate (laughs).

Yeah, that was, it was, ya know, that was really helpful. Because I've been thinking about this, I guess, in terms of the fact that the bacteria develop resistance to the anti microbials. And that this is something that they can pass on to each other. And so there seems to be this, you know, environmental pressure upon them when you have greater exposure to them and stuff like that. But that's what you're saying is the manmade part. And we can actually imagine otherwise scenario where lots of places that currently have lots of unregulated access to like tetracycline don't have that anymore, and could be preserving it better.

Yeah, I think that's part of it. But I also so I think, in part, it's just trying to get the conversation to a new place or to kind of see it doesn't mean it's gonna be easy, right? So just because the papers published we know very well, doesn't change things in... and again, it doesn't mean that there isn't depletion, but to your point, right... We need to take seriously the fact that we have different health care systems that are different kinds of functioning, and that that's a history of colonialism that's baked into that, right, so this goes back to the public health part that I think now I'm just editorialising. But we're not. That we often kind of forget in the in the health security part, right, is that it is a hist... that we are functioning under the guises under the the history of colonialism and the history of exploitation. Right. So, okay, let's acknowledge that and see if we can do something different, at least be clear as to the assumptions and the values.

And is that is there something about that framing that is important to thinking of this as a health security issue, rather than just a public health issue? Like, is there something about the fact of the nation state and different healthcare systems that makes it a health security issue?

So, so I think that I think that the reason it's a health security issue? Well, so first of all, I don't think it's exclusively a health security issue. So many of our colleagues have been writing about this in the context of public health ethics, and I think correctly, so, right? So it's not exclusively, I think what makes it a health security issue is the international border aspect, for example. And the fact that you are trying to securitise... make, make, make the idea of anti microbials as a category of thing, reliable into the future. And here, I'm kind of drawing on John Harrington's work on on security in the ethics of security, this idea of making this reliable to the future. So I think I think health security has a role in this. But I don't think I don't think it's clear. And I think it's it depends on the perspective rather than anything intrinsic to the issue itself.

This has been really interesting. And I guess we're kind of coming towards the end of our time. But I did want to ask, I still have a couple of questions. So I wondered if there was anything that was particularly challenging about writing the paper or doing the research for the paper?

I mean, one thing I found, challenge... well, this was probably the first time I probably use this methodology, the critical interpretive review. And so, you know, there's... it's not a systematic review, in the sense that you're literally pulling together every relevant article. And and kind of aggregating the findings that way, it's more of a method that, you know, I guess, suits interdisciplinary papers that you're drawing on, and contested concepts, and that kind of thing, and trying to get a summary of the literature as a whole and add to that conversation and kind of glean some theory from it. So that was relatively new for me. And I think just being able to, I guess, I think some of the feedback that we received from the reviewers was pretty fair, in terms of, you know, you're at this taking it... there's is almost a step away from the literature in the sense that you are kind of reading what it's saying as a whole. And so, you know, being making sure that the findings are very closely linked to, or sorry, your interpretations are very closely linked to your findings, and being able to kind of make sure that the evidence is all in there and all nicely in the paper, and make sure that that's all squared away. So that was, I guess, one challenge that I've found. And that's why I guess we also had the supplementary quotes table as well, just to make sure that kind of all the evidence is there, and that all those links were solid.

Makes sense. And I wonder, as the final question, because I feel like this is quite an interesting and perhaps important paper. And I wonder if there's any, like sort of one or two things that you hope that people will take away from it, having read it?

Yeah. So from my perspective, I think it's this idea of trying to think differently. And I think, to the credit of certain of our colleagues in bioethics, this, this has already begun. But I think we have a role in bioethics of advocacy, to advocate for trying to think about the world around anti microbials differently. And to say, look, there's a different way that we can think about this. Because as it currently stands, it does seem like it's a problem, the tragedy of the commons, it does seem like it's a wicked problem. So we need to, and again, there's people who have already started working on this, and I think for us, it's just kind of adding to that choir to be like, Look, this is too important to sort of have it be business as usual.

Yeah, and I would only otherwise add that I guess you could extrapolate this to... well something I and took away from it is that you can extrapolate these potentially to other wicked problems so to say like, you know, what, essentially we're arguing is not that, I guess the point of the paper wasn't to say that one set of values is stronger than the other set of values necessarily, but to say that it's important to have that deliberation and that articulation kind of in the public sphere, and to say that it's important to, you know, the values that I guess underpin the position you're coming from, from a policy perspective has implications on how you respond to it on how you conceptualise it on how you allocate resources on how you prioritise it, or deprioritise it. So I guess, that's the takeaway for me is also just to articulate those values and make sure we're clear where we're coming from and what that means from a policy perspective. And that is relevant to AMR, but it's also relevant to probably a lot of other wicked problems, so to say.

Yeah, absolutely. And I love that phrase, the wicked problem. Yep. Well, thank you so much for talking with me, Diego and Kari, it was really great.

My pleasure.

Thank you.

Yeah. Awesome. And thank you so much for listening to this episode of the SHE Research Podcast. You can find Diego and Kari's paper linked in this episode's notes, along with a transcript of our conversation. SHE Pod is hosted by me Kathryn McKay and produced by Madeline Goldberger. You can find our other episodes on Spotify, Radio Public, Anchor or wherever you get your podcasts of quality. Thanks again for listening. Bye.