The 'Dark Ages' - a misused metaphor for a post-antibiotic future - Somatosphere
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Science, Medicine, and Anthropology
http://somatosphere.net
The ‘Dark Ages’ – a misused metaphor for a
post-antibiotic future
2020-08-10 21:50:18
By
In 2014, then Prime Minister David Cameron told the British public that
‘we are in danger of going back to the Dark Ages of medicine.’ He was
introducing the UK government commissioned Review on Antimicrobial
Resistance (AMR), which projected that there would be 10 million deaths
per year due to AMR by 2050. While Cameron did not invent the ‘Dark
Ages’ metaphor with regard to AMR, this language and imagery has
spread social media, TED talks, YouTube, documentaries, and research.
Across various types of media, audiences are told that ‘modern medicine’
as we know it will cease to exist when antibiotics stop working due to
antimicrobial resistance; a return to the Dark Ages – or at the very least
the pre-antibiotic era – awaits us.
There is some truth to this. Not only are antibiotics used to treat acute
infections, but they are also used prophylactically in routine surgeries and
in procedures that compromise the immune system, such as in
chemotherapy. However, using the Dark Ages as a metaphor to imagine a
post-antibiotic era is flawed, as are any comparisons to the pre-antibiotic
era. Firstly, many aspects of scientific knowledge and practice have
changed not only since the ‘Dark Ages’ but also since penicillin entered
medical use in 1942. Secondly, many of our risk factors and protective
factors are also different. In her 2015 TED Talk, journalist Maryn McKenna
reminds an audience in Vancouver that in the pre-antibiotic era people
died of infections after ‘being gored by an ox, shot on a battlefield, or
crushed in one of the new factories of the industrial revolution.’ Even if
antibiotics stop working, these are hardly everyday hazards that most 21st
Century Canadians would need to worry about.
In this essay, I start with a short definition of ‘the Dark Ages’ and then
discuss how this is a poor metaphor for imagining the future. I then
examine how this metaphor – along with associated language and
imagery around catastrophe and apocalypse – reflects contemporary
societal anxieties. In doing so, I draw upon dystopian fiction, as well as
social science thinking. Finally, I conclude by presenting a more hopeful
image of a liveable post-antibiotic future.
The Dark Ages – a brighter picture
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The term ‘the Dark Ages’ typically refers to the Middle Ages or Medieval
period in Europe (5th to 15th Centuries), more commonly the early Middle
Ages (5th to 10th Centuries). In popular culture, the Dark Ages are
associated with words like ‘struggle,’ ‘brutal,’ ‘disease,’ ‘violence,’
‘filth,’ and ‘famine.’ For many, it is visualised as a time in which serfs
and peasants lived harsh lives in fear of Viking invasions or the plague.
Indeed when ‘medieval medicine’ comes up in conversation, leeches and
pestilence spring to mind. It is a time of ‘superstition and religion’ instead
of science.
This is, of course, an imagined history and there are many misconceptions
about the Dark Ages, in general, and medical practices of the time,
specifically (Van Arsdall 2008; Getz 1998). This is partly because relatively
few written records exist from the time, so we have used our own biases to
fill in the gaps. Many of the records that do exist come from Roman writers
at the end of the Roman Empire, or from later writers – particularly those
during the Age of Enlightenment – who viewed Rome as the height of
civilisation; these are similarly tinged with biases of their respective eras
(Wells 2008). Today, most historians avoid the ‘Dark Ages’ label, and
recent research in history and archaeology indicates that rather than being
a backwards regression from the Roman Empire, it was in fact ‘a time of
brilliant activity’ (Wells 2008).’
During this time, medicine was not practiced in absence of empiricism or
scholarship. Rather, depending on time and places, many medieval
medical practices were based on Greek, Roman, and Islamic medical
beliefs, as well as local practices (Getz 1998). This is not to suggest that
life was easy during these centuries: as imagined, leprosy and plague
were two particularly prevalent diseases in the Middle Ages (Getz 1998,
80). However, medieval health conditions and medical practices were far
more nuanced than in our contemporary imagination.
Overall, Historian Faye Getz has suggested that the way in which healing
was organised and practiced in the Middle Ages is so different from today
that it is not useful to try and draw comparisons with contemporary
medicine. Instead, she suggests we take the anthropologist’s perspective,
and view medieval medicine as a logical system based on society’s
conception of the natural world.
But rather than discussing an actual time period, I am interested in the
Dark Ages as an imagined place outside of time and space. The Dark
Ages metaphor refers to ‘backwardness’ and ‘the other.’ A humorous
example comes from Star Trek IV: The Voyage Home (1986) in which
Captain Kirk and the crew of the Enterprise travel back in time to 1986.
After an injury, Chekov ends up in a hospital and needs to be rescued:
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Dr McCoy sees a woman lying on a gurney in the corridor and
moaning. He asks what is wrong and when she answers with
‘dialysis,’ he replies:
“Dialysis – my god, what is this, the Dark Ages?
He then meets two junior doctors in the lift, discussing senior
doctors disagreeing over chemotherapy or image therapy. When
asked if he has an opinion, McCoy replies with:
’Sounds like the goddamn Spanish Inquisition to me”
Then, when they find Chekov in the surgical theatre, McCoy’s
assessment of the situation is that ‘we’re dealing with
medievalism here”
While these scenes take a light-hearted approach to the ‘Dark Ages’
metaphor, in real life it is generally pejorative, often reflecting racism and
xenophobia. Researching online comments around ‘the Dark Ages’ in
relation to AMR, sociologists Nik Brown and Sarah Nettleton find ‘barely
publishable’ language about ‘the other’ – often people in low-income
countries, immigrants and/or Muslims – who are accused of living in the
Dark Ages now (Brown and Nettleton 2017, 501). A key method in my own
research on AMR is sitting in my pajamas watching YouTube. While many
think they would enjoy this, it is challenging and exhausting to watch
factually inaccurate, implicitly or explicitly racist and anti-Semitic videos for
hours on end.
AMR and our appetite for dystopias
Social science researchers, predominately from sociology, have examined
not only the ‘Dark Ages’ but also other related metaphors around AMR.
For instance, Brigitte Nerlich, along with Brian Brown and Paul Crawford,
has looked at catastrophic and apocalyptic language (Nerlich 2009; Brown
and Crawford 2009). Brown and Nettleton have argued that AMR ‘has
become a medium for the expression of a prevailing cultural ambivalence
about hygiene, dirt, nature, infections, bugs and the non-self or immunity
“other.”’ That is, AMR is ‘a canvass for the projection of wider
existential insecurities’ (Brown and Nettleton 2017, 495, 501).
Writing on AMR, Brown and Crawford use Sociologist Sheldon Ungar’s
notion of this ‘mutation-contagion package’:
microbes and the environment are conjoined in an ecological
parable involving population growth and antibiotic overuse, and
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with microbes knowing no boundaries (globalisation), and the
notion that we are waiting for the next plague (Brown and Crawford
2009, 510)
Drawing upon Jean-François Lyotard and Mary Douglas, they further
argue that
The sense of technological advance and progress in fighting
infection – the sense of emancipation through scientific progress –
is challenged by popular and technical discourses detailing the
hazards of a sojourn in hospital. a perceived threat to deeply held
beliefs about material, moral, or social order (Brown and Crawford
2009, 508)
Dystopian fiction offers similar theoretical perspectives for understanding
why we are drawn to Dark Ages, apocalyptic and catastrophic language,
and how this language reflects uncomfortable truths about contemporary
society. It often serves as a commentary on current values, society,
politics and fears; and as a warning of what may happen if we do not
change our behaviour (cf. Demerjian 2016). In this way, the dark age
metaphor is about projecting our fears both forwards and backwards in
time.
A main theme in dystopian fiction is that technology that has run amok (cf
Barton 2016; Stein 2016; Tiehen, 2016; Stapelton 2016). This is based on
a paradox that we were promised that technology would save us, but it
has instead destroyed us. A related narrative is that of ‘nature fighting
back,’ where we thought that we could conquer nature, but instead realise
too late that this is mere folly. Another set of themes in dystopian fiction is
centered around the notion of conspiracy theories and ‘blaming others.’
In many examples of dystopian fiction, society has become xenophobic in
the aftermath of an environmental or technological disaster (Barton, 2016).
Blame and conspiracy theories represent ways to deal with
insurmountable problems and explaining why one’s group has suffered.
Comparing themes in dystopian fiction to AMR discourse helps us
understand the invocation of metaphors about the ‘Dark Ages’ . If
antibiotics are the ‘measure and benchmark of modern medicine’ (Brown
and Nettleton 2017, 500), then they have failed. But they have failed
because we have misused them on both humans and animals and they no
longer work. Instead we are left with a collective grief that modernity and
rationality failed, that the ‘golden age’ of medicine is over. Our narcissist
thinking, that we humans could conquer microbes, was mere folly. ‘The
other’ causing or spreading resistance may be doctors who prescribe too
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many antibiotics or patients who demand them. It may be ‘immigrants’
who come from ‘dark age countries,’ bringing AMR to wealthier countries.
(Here we ignore a number of ugly truths – not least that high income
countries consume pharmaceutical products produced in middle-income
countries, where the pharmaceutical waste contribute to the AMR
problem.)
In describing AMR, the ‘Dark Ages’ metaphor does not refer to the
Middle Ages in Europe, but rather to an imaged place outside of time and
space on which we project our own fears and biases about technology,
modern medicine, and ‘the other.’
Beyond metaphors – a liveable post-antibiotic future
Health metaphors have potentially negative impacts on how we
understand the body, health risks, and disease, with tangible impacts upon
healthcare, research, and society at large (Cobb 2020; Nerlich 2008;
Martin 1991). Comparing climate change science to AMR, Nerlich asks
whether or not catastrophic language helps or hinders the cause: “Do
people feel empowered to do something, or do they just feel powerless
and do not act; attention grabbing versus fear? (Nerlich 2009, 577).”
The current proposed solutions to AMR as a societal challenge are limited
by our contemporary imagination. Alarmist language – including the Dark
Ages metaphor – has been used to define AMR as an economic problem
(Brown and Nettleton, 2017). The idea is that we need market-based
solutions to encourage pharmaceutical companies to invest in new
antibiotics arises frequently in the publications coming out of the UK’s
Review on Antimicrobial Resistance. Ironically, in many ways the market
has already created a post-antibiotic dystopia in the form of
pharmaceutical waste in rivers and animal husbandry practices based on
overuse of antibiotics in animals.
I do agree that we need new antibiotics, but market-based solutions are
not the only way to develop them. I doubt we are returning to feudalism
but rather we may be moving towards a way of organising society we have
not yet considered. I also suggest that the use of history-as-future
metaphors, alongside apocalyptic and catastrophic language, prevents us
from thinking calmly and hopefully about a liveable post-antibiotic era.
So, if it will not be a return to the Dark Ages, what does a liveable
antibiotic future look like?
Firstly, there are limits to how the past can help us imagine the future.
Science fiction from the 1950s or 1960s often reflected or subverted social
norms from those decades when portraying the future. For instance,
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themes around racial or gender equality feature in Star Trek: The Original
Series (1966-1969). Nevertheless, there were limits on the extent to which
the series could imagine a future beyond the social norms of the time:
while there was an African American, female bridge officer, there were
also many examples of Captain Kirk seducing alien women in a way that
may have been acceptable in the 1960s but not in 2020. When it comes to
antimicrobial resistance, contemporary social norms place limits not only
on how we imagine the future, but also on how we imagine future
solutions, and the roadmap for achieving these solutions. Even if
antibiotics stop working, this does not mean that the plague will return.
Nor will we be gored by oxen.
Secondly, while the future is not the past, the past reminds us that all
things are possible. One hundred years ago, eradicating smallpox was
not even an idea. Now it is a reality. Even if society has anxieties and
doubts about technology, there are technologies that we cannot even
imagine today. History also helps us to remember the paths not chosen.
For instance, phage therapy for combating bacterial infections is only now
being rediscovered by ‘Western countries’ even though it has been used
for decades in places such as Georgia.
Thirdly, we need a shift towards preventing disease. Again, at the risk of
contradicting myself, the past does actually offer solutions. In 2013 then
UK Chief Medical Officer Dame Sally Davies spoke of ‘rediscovering
hygiene.’ In another example, Ulf Högberg has argued that drastic
declines in maternal mortality in Sweden occurred before the advent of
‘modern medicine’ due to the introduction of trained midwives and
antiseptic techniques (Högberg 2004). Other non-antibiotic ways of
addressing infection include ensuring clean and safe housing, better
ventilation in hospitals, safer roads (to decrease infections after road traffic
accidents) and preventing conditions that lower immunity, such as Type- II
diabetes. A current example from real life is the current coronavirus
pandemic, where preventive measures (social distancing, hand washing,
etc.) are at the absolute forefront. In these cases, there is also a clear
need to reduce inequalities in the social determinants of health.
Finally, while one should be hesitant to compare the mosaic of practices
and beliefs of ‘medieval medicine’ to today, there is some applicability in
the comparison. In general, medieval medical practices offered more
holistic approaches to life and the body. There was a great deal of
emphasis on what we today might think of as ‘wellness’ or lifestyle advice
(Getz 1998). There was also a focus on ‘Christian charity’ in the project
of helping poor: the provision of food, shelter and protection which
certainly contributed to decreased risks of infection (Getz 1998, 90).
The Dark Ages were not all dark, and neither does a post-antibiotic future
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need to be. In the meantime, I need to go and wash my hands.
Rachel Irwin is a researcher in ethnology in the Department of Arts and
Cultural Sciences at Lund University. This commentary comes out of the
interdisciplinary Post-Antibiotic Futures theme at the Pufendorf Institute for
Advanced Studies, Lund University.
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