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
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:
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 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 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, 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 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.
Brown, Brian and Paul Crawford. 2009. ‘”Post-antibiotic apocalypse.’ Discourses of mutation in narratives of MRSA.” Sociology of Health & Illness 31, no. 4: 508–524. https://doi.org/10.1111/j.1467-9566.2008.01147.x
Brown, Nik and Sarah Nettleton. 2017 “‘There is worse to come’: The biopolitics of traumatism in antimicrobial resistance.” The Sociological Review 65, no. 3:493-508. https://doi.org/10.1111/1467-954X.12446
Barton, Riven. 2016. “Dystopia and the Promethean Nightmare.” In The age of dystopia: one genre, our fears and our future, edited by Louisa Mackay Demerjian, 5-18. Newcastle upon Tyne: Cambridge Scholars Publishing.
Chandler, Clare. 2020. “Current accounts of antimicrobial resistance: stabilisation, individualisation and antibiotics as infrastructure,” Palgrave Communications 5, no. 53. https://doi.org/10.1057/s41599-019-0263-4
Cobb, Matthew. 2020. “Why your brain is not a computer.” The Guardian, Feb 27, 2020. https://www.theguardian.com/science/2020/feb/27/why-your-brain-is-not-a-computer-neuroscience-neural-networks-consciousness
Davies, Dame Sally. 2013. “The drugs don’t work.” Filmed October 2, 2013 at TEDxAlbertopolis, London. https://www.youtube.com/watch?v=7evvWt8XN7o
Demerjian, Louisa Mackay. 2016. “Introduction.” In The age of dystopia: one genre, our fears and our future, edited by Louisa Mackay Demerjian, 1-4. Newcastle upon Tyne: Cambridge Scholars Publishing.
Getz, Faye. 1998. Medicine in the English Middle Ages. Princeton: Princeton University Press.
Högberg, Ulf. 2004. The Decline in Maternal Mortality in Sweden: The Role of Community Midwifery. https://doi.org/10.2105/ajph.94.8.1312
de Kraker, Marlieke E. A., Andrew J. Stewardson, Stephan Harbarth. 2016. “Will 10 Million People Die a Year due to Antimicrobial Resistance by 2050? PloS Medicine. 13, no.11. https://doi.org10.1371/journal.pmed.1002184
Larabee, Ann. 2000. Decade of Disaster. Champaign, IL: University of Illinois Press.
Martin, Emily. “The Egg and the Sperm: How Science has Constructed a Romance Based on Stereotypical Male-Female Roles. Signs. 16, no.3:485-501. http://www.jstor.org/stable/3174586
McKenna. Maryn. 2015. “What do we do when antibiotics don’t work any more?” Filmed June 25, 2015 at TED Vancouver, BC. https://www.youtube.com/watch?v=o3oDpCb7VqI
Nerlich, Birgitte. 2009. “’The post-antibiotic apocalypse’ and the ‘war on superbugs:’ catastrophe discourse in microbiology, its rhetorical form and political function.” Public Understanding of Science. 18, no. 5:574–590 https://doi.org/10.1177/0963662507087974
Nichter, Mark. 2010. “Idioms of Distress Revisited.” Culture, Medicine and Psychiatry 34:401-416. https://doi.org/10.1007/s11013-010-9179-6
Nichter, Mark. 1981. “Idioms of distress: alternatives in the expression of psychosocial distress: a case study from South India.” Culture, Medicine and Psychiatry 5, no. 4:379-408. https://doi.org/10.1007/BF00054782
Stapelton, Patricia. 2016. “‘The people in the Chaos Cannot Learn:’ Dystopian Vision in Atwoord’s Maddaddam Trilogy.” In The age of dystopia: one genre, our fears and our future, edited by Louisa Mackay Demerjian, 19-34. Newcastle upon Tyne: Cambridge Scholars Publishing.
Stein, Karen F. “Post-apocalypse, post-human: some recent dystopias.” In The age of dystopia: one genre, our fears and our future, edited by Louisa Mackay Demerjian, 47-58. Newcastle upon Tyne: Cambridge Scholars Publishing.
Tiehen, Jeanne. 2016. “Dystopian drama: imaging science without limitations.” In The age of dystopia: one genre, our fears and our future, edited by Louisa Mackay Demerjian, 59-72. Newcastle upon Tyne: Cambridge Scholars Publishing.
Ungar, S. (1998) Hot crises and media reassurance, British Journal of Sociology, 49, 36–56. https://10.2307/591262
US National Library of Medicine. 1947. “Easy to Get” Film by the US Army Service Forces. https://www.youtube.com/watch?v=T-q30cMxRgQ
Van Arsdall, Anne. 2008. “Rehabilitating Medieval Medicine. In Misconceptions about the Middle Ages, edited by Stephen J. Harris and Bryon L. Grigsby, 135-141. New York and London: Routledge
Walston Joseph, Terra. 2016. “Victims of Global Capitalism in Margaret Atwood’s Dystopian Imaginary.” In The age of dystopia: one genre, our fears and our future, edited by Louisa Mackay Demerjian, 35-46. Newcastle upon Tyne: Cambridge Scholars Publishing.
Wells, Peter S. 2008. Barbarian to Angels. The Dark Ages Reconsidered. New York and London: W.W. Norton and Company.
Walsh, Fergus. 2014. “Antibiotic resistance: Cameron warns of a medical ‘dark ages’.” BBC, July 2, 2014. https://www.bbc.com/news/health-28098838