Heather Borror

Honors 393

19 December 2016

On Solutions to the Problem of Antibiotic Resistance

I have chosen to analyze an article calling the medical community to action: The

Epidemic of Antibiotic-Resistant Infections: A Call to Action for the Medical Community from

the Infectious Diseases Society of America. I was initially interested by this subject because of

my background in biochemistry, and my awareness for the troubling problem that antibiotic

resistance poses for public health. This article in particular captured my attention because it was

written by physicians and researchers for their peers, asking them to act and make change in the

public sphere that is, to say, beyond the scope of their practice. This aspect alone made this

article personally worth studying as I hope to someday become a physician myself: the better I

can understand how to communicate effectively with my colleagues and patients, the better I will

be able to serve my community.

The body of the article is organized into eight major sections, nine including the abstract.

In the abstract, the authors wish to discuss the problem of antibiotic-resistant infections in terms

of what has been done, why it is happening, what the authors would like to do about it, and how

they would like the readers to act. The introduction frames the article by describing the severity

of the problem of antibiotic resistant bacteria, then explicitly explains to the reader the three-part

purpose of the paper: to review the causes of this societal conundrum, to summarize the IDSAs

response to date, and to urge immediate grassroots action.1 The article transitions into a

summary of the scientific reasoning behind antibiotic resistance, and then provides an

explanation for decrease in antibiotic development. Subsequently, the authors detail the IDSAs
1 Brad Spellberg et al., The Epidemic of Antibiotic-Resistant Infections: A Call to Action for the Medical Community from the Infectious
Diseases Society of America. Clinical Infectious Diseases 46 (2008): 156.

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previous responses as well as those of Congress. At this point, the authors present a list of

proposed actions to keep antibiotics available and effective for the long term, many of which

have to do with creating governmental programs to monitor antibiotic resistance and support

research and development.2 The authors then propose a list of financial incentives that should be

enacted in order to support the points made in the first list. Then the authors insist, in an aside,

that new antibiotics cannot be replaced by novel immunotherapies. The authors round out their

article with a section describing potential actions that could be taken by individual members of

the medical community more precisely, the readers themselves and a section describing the

authors conclusions.

The proposed solutions may strike the careful reader as potentially controversial. Such

calls to support increased funding for pharmaceutical industry, particularly the call to extend

patent life for priority antibiotics.3 This may raise the concern that the authors are trying to steer

their audience to prioritize business interests, potentially at the expense of serving patients. It

would be reasonable to be concerned, especially considering events such as Turing

Pharmaceuticals decision in 2015 to drastically raise the price of Daraprim a potentially

lifesaving drug for those who are HIV positive and Mylans decision to raise the price of

emergency epinephrine pens only months ago.4,5

The strength of the articles rhetorical approach, however, is reflected in the large number

of positive responses to their article, save for one.6 Even so, this article does not go to great

lengths to criticize the proposed measures of the Spellberg et al. paper, merely commenting that

their proposals are questionable given the numerous potential conflicts of interest.7 Indeed, in the

2 Ibid., 160.
3 Ibid., 160.
4 http://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html.
5 http://www.nytimes.com/2016/08/25/business/mylan-raised-epipens-price-before-the-expected-arrival-of-a-generic.html.
6 Calvin M. Kunin, "Why Did It Take the Infectious Diseases Society of America So Long to Address the Problem of Antibiotic Resistance,"
Clinical Infectious Diseases 46 (2008): 1791-2.
7 Ibid., 1791.

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acknowledgements section at the end of the piece, the majority of the authors are noted to have

collaborated with the industry that they seek to support, whether it be an advisor to the board or

as a researcher that has received corporate funding.8 Because of its success in persuading its

audience to accept potentially controversial statement, I believe that the Spellberg et al. article is

particularly worth rhetorically dissecting.

I have found that the authors style their appeal as a research report and by rhetorically

deflecting blame away from pharmaceutical companies in a variety of ways, notably before

explicitly proposing their solutions. The authors present their case in a way that engenders

urgency while maintaining a sense of rationality, allowing themselves and their solutions to be

perceived as trustworthy and logical.

The format of the text itself creates a sense of credibility, especially as a part of this particular

publication. It is styled as a research report both in layout and content. This establishes the

impression that Spellberg et al. has been peer-reviewed and approved, just like the articles

around it. Regarding the specifics of the organization, after the title, the authors and their

affiliations are listed, and prior to the body of the article is the abstract. This further allows the

readers to determine the credibility of the article: the audience sees which institutions to which

these authors belong. In this article, the authors are shown to be affiliated with a variety of

hospitals and universities, adding to the authors reliability on the subject matter. The audience is

also allowed a summary of the paper itself, from which they can determine whether or not this

particular article is worth reading further. As a persuasive article, this general format is a

compelling framework that inclines the reader to trust the material before he/she has even had a

chance to read it.

8 Spellberg et al., 162.

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 In terms of sequential presentation of ideas, the Spellberg et al. article provides

substantial background information before presenting their solution. This allows them to feed the

reader with carefully chosen information: in other words, the authors can strategically present

information to the reader in order to reach to a conclusion that aligns with the authors intended

direction. This background information includes reporting on the efforts made show that the

authors, belonging to the IDSA, have taken measures to drum up public support, citing

collaborations with several major public and private institutions.9 As it demonstrates that their

work has gained traction with such powerful groups, invoking the names of these institutions

provides yet another layer of credibility. This could be considered an appeal to authority.

Prior to introducing the solutions and after, urgency is created throughout the article.

Beginning with the introduction, the authors declare that [w]e are in the midst of an emerging

crisis that will impact clinicians practicing in every field of medicine, and calling multidrug-

resistant microbes a substantial threat to US public health and national security. 10 They also

explain that previous movements in US policy to support research and development have been

insufficient to meet the challenge put forth by resistant bacteria. Strong language is employed,

such as when pharmaceutical companies are said to be abandoning the development of anti-

infectives, that there are no signs that newer and better antibiotics will be developed in the

next decade, and that the authors want to address the need to significantly revitalize antibiotic

R&D. 11 In short, they describe the development of new antibiotics as something that has been

allowed to stagnate and is in jeopardy of dying.

The authors also suggest that the medical community has previously underestimated the

power of microbial adaptation. They humble the human being against the microbe, reminding the

9 Ibid., 158-159.
10 Ibid., 155-156.
11 Emphasis is my own, unless otherwise noted.

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reader just how many of them there are against how many of us. Appealing to scientific topoi,

the authors do not simply tell the readers that there are many more of them and that they adapt

rapidly: they bolster their claims with numbers and data. This serves the call to action, creating

urgency by telling its audience that they cannot afford to be complacent with the current progress

of research and development.

Urgency is also created when the authors go beyond answering the question they pose at

the beginning of a section. The authors pose the question What is the cause of antibiotic

resistance? and they answer it by explaining bacterial capacities for adaptation, but in the same

section they explain what humans can do to influence it, jumping into describing what

physicians should do, how they should act. 12 This demonstrates that the authors cant wait to

explain what their readers can do to combat the issue, and perhaps that the readers shouldnt.

Also __ In the section about congresss actions, the authors note that what bills have been

passed are only the first concrete, positive steps toward beginning to address the crisis, further

reminding their audience that there is much progress still to be made. 13 They also note that

Unfortunately, as a whole, the 109th Congress focused on other priorities. If one believes that

the issues dealt with by Congress first are those that society is keen on, this is an indicator that

the cause against antibiotic resistant infections is not pressing on the mind of the people. This

appeals to the sense of responsibility readers may feel as members of the medical community.

This urgency is tempered, however. It is kept from becoming sensationalistic by the

authors rational approach. Considering that this journal, Clinical Infectious Diseases, is written

for medical researchers and practitioners, for such an audience an appeal to logic is crucial to

establish.14 This occurs in both overt and subtle ways. For instance, while the authors describe

12 Ibid., 156-157.
13 Ibid., 159-160.
14 http://www.oxfordjournals.org/our_journals/cid/about.html

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antibiotic resistance as a crisis, they also frame it as one that can be rationally dealt with: the

authors state that they would like to review the causes of this societal conundrum.15 The word

conundrum is evocative of difficult problems, but also of puzzles: something challenging that has

a logical solution. This subtly prepares the audience for the authors solutions to come.

The authors also demonstrate bipartisan support from Congress.16 In their discussion of

Congresss actions on behalf of their cause, the authors provide the reader with a list of different

representatives that are currently collaborating with the IDSA. Because there are representatives

from both parties with different ideologies, this suggests that there is a fundamental level of truth

to the IDSAs cause, conferring credibility to their actions and goals.

Also in the background information, Spellberg et al. create urgency in a rational way by

indicating how the human ability control over antibiotic resistance is inherently limited. When

providing background information on the issue of antibiotic resistance, the authors characterize

microbes as something beyond our control. Humans do not have agency over them, and

Spellberg et al. remind us that they do not need us in order to create resistance to threats to their

own survival.17 Highlighting the fact that the bacterial capacity to adapt are beyond our control as

we know it supports the call to find new ways to deal with the problem.

In discussing this limited control, the authors also address the problematic metaphor of

countering antibiotic resistance as a battle. In Segal 1997, she describes how it can be

problematic to use such a metaphor as it creates enemies that cannot necessarily be overcome,

such as death itself.18 In the Spellberg et al. article, the authors recognize the similar problem

with characterizing evolving microbes as such an enemy to defeat. They note that their

weapons against bacteria are antibiotics, but remind their audience that human beings did not
15 Brad Spellberg et al., 155-156
16 Ibid., 159.
17 Ibid., 157.
18 Judy Z. Segal. Public Discourse and Public Policy: Some Ways That Metaphor Constrains Health (Care). Journal of Medical Humanities
18, no. 4 (1997): 223.

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invent them; we merely discovered them. The authors then use the same metaphor, yet in an

ironic sense: We must concede that we will never truly defeat microbial resistance.

Interestingly, because this issue is established to be one that is beyond the human

capacity to control, this establishes a sense that this situation is one in which there are no

enemies. This serves the authors deflection of blame from pharmaceutical companies, even

before explicit mention is made of their proposed solutions.

The use of the word unfortunately serves a similar function. It appears nine times

throughout the document, used four times in one page at one point.19 This subtly implies that this

issue has to do with a lack of fortune or luck again, something beyond anybodys control. Thus,

there is nobody to blame.

This idea is also reflected in the usage of the natural disaster metaphor. One major section

title calls the combination of increasing resistance and lack of research as a perfect storm,

further communicating the need to act: this problem is as dangerous as a natural disaster. 20 This

metaphor is particularly intriguing because it suppresses blame, prior to the authors even

mentioning the pharmaceutical company in the first place.

Upon presenting their list of solutions, Spellberg et al. defend the interests of

pharmaceutical companies outright. The element of rationality is present in the authors defense

of the pharmaceutical industry, as they frame their solutions as the most pragmatic course of

action.

They claim that the companies themselves are not necessarily to blame for the lack of

research: company directors do have a financial responsibility to make decisions that will make

the best returns on their investment. 21 This also contributes to the call to action and the sense of

19 Spellberg et al., 156.

20 Ibid., 156-158.
21 Ibid, 161.

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urgency, because the authors claim companies cannot realistically be expected to act only in the

interest of the public good over profit: they maintain that this is a systemic issue of society and

government. Such an indication, requiring change within larger social and governmental

institutions, also supports the need for readers to act. The authors of the paper, despite findings

from their own research and education, cannot act alone to engender the greater institutional

change they require the support of their community.

The call to extend the patent life of priority antibiotics is also defended the authors

believe that it would be sensible to prevent important antibiotics from being overused: making

such antibiotics cheaper will not necessarily help the issue.22 Given the prior background

information on the genetic reasons behind antibiotics, they reason that making them less

accessible will make the drugs them more effective when they are used.

The Segal article also discusses the influence of the metaphor of medicine as a business,

inverting the primary beneficiary of care as the profiting business rather than the patient. 23 The

authors similarly recognize the widespread consideration of antibiotic drugs as a product, and

they cite the lack of return on investment as a key issue in funding research, as well as the fact

that the FDA provided only vague guidelines for researchers, limiting their ability to effectively

use what funding they do have. 24 The authors allow a bit of tongue-in-cheek, comparing growth

of new antibiotic research to growth in development of drugs for erectile dysfunction this

demonstrates an element of frustration with the situation, and the system itself. For those in the

audience that may feel like their concerns about the pharmaceutical industrys priorities go

unaddressed, this little snippet may reach them.

22 Ibid.
23 Segal, 225.
24 Spellberg et al., 158.

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 The employment of the metaphor of conservationist environmentalism is also relevant to

Spellberg et al.s pragmatic approach. The authors make a direct comparison of antibiotics with

natural resources: things that have existed since before humans, such as oil and forests, but are in

danger of being depleted.25 This serves to humble their audience, reminding them of the

challenges humankind must deal with in order to survive alongside such sophisticated and

experienced organisms. However, as per the metaphor, we are compelled to continue using those

resources because we have not developed anything that works quite as well yet. This potentially

gives them a sense of rational appeal: we are doing the practical thing by trying to preserve the

current model of consumption.

The short section on immunotherapies serves to support this idea.26 This section is well-

placed rhetorically, as it follows the wish-lists immediately, thus giving the authors another

opportunity to defend their proposed actions. Here, the authors claim that new immunotherapies

are not enough: while such innovations deserve to be a major focus of research and

development, the authors still conclude that it would be nave to think that novel

immunotherapies could replace the need for new antibiotics. 27 By claiming such a thing, it

reinforces the idea that the medical community must still make the most of the existing model of

treatment.

This also ties back into an interesting contradiction in the authors criticism of the war

metaphor. Despite pointing out its problematic connotations, the authors still cannot quite escape

its usage: they want to improve targeted therapy, they want to combat antibiotic-resistant

infection, and they describe how the IDSA is performing on the regulatory front.28 This

25 Ibid., 157.
26 Ibid., 161.
27 Ibid, 161.
28 Ibid, 157, 159.

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communicates a desire, intentional or not, to maintain the current paradigm instead of striving to

create a new one.

Finally, Spellberg et al. drive their message home by speaking directly to the readers

themselves at the end. The authors remind the readers of the social responsibility they hold by

virtue of their career that [o]nly the medical community can provide an accurate perspective

and rational balance to this issue. 29 The example of bioterrorism reminds the audience that they

cannot allow more irrational threats to overshadow the damage done by real ones. By waiting

until the end to speak to the audience directly, using you, is possible that the audience now

feels the weight developed by the contents of the article falls to them.

Conducting this analysis really forced me to consider the relationship between healthcare

and the free market. I would like to believe that the case the authors are making is one they

genuinely believe in, beyond the potential for personal profit. Despite the fact that they have ties

to the pharmaceutical industry, the authors are all individuals that serve the public as medical

professionals. Additionally, in my mind, pharmaceutical companies need such informed

individuals to have a hand in steering the business in order to maintain balance. In our

capitalistic society, perhaps this was unavoidable. It also raises the question to me of how it

would be best deal with dangerous, immediate problems of public health: is it best to try to make

changes in the larger system, or to work within it? Such questions do not have simple answers. In

the end, Spellberg et al. rightly establish that this is an issue not to be underestimated, one that

must be actively confronted and monitored. There may never be a solution that will be

universally satisfactory, but that shouldnt deter anybody from advocating for what they believe

is best.

29 Ibid, 161-162.

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