A 'wicked problem'
The concept of 'wicked problem' was originally launched in an article by Rittel and Webber (9). The English word 'wicked' can have connotations of 'intricate' or 'malignant', but we have chosen to use the term in line with recent publications in the social sciences (10). The key insight from this research is that some social problems are so complex and have so many different causes that we cannot expect to solve them, and that at best, we can only minimise their negative effects. Rittel and Webber define ten properties of 'wicked problems' (Table 1) that explain why they cannot be solved through political interventions that may be either well-placed or misjudged. Many of these properties are clearly recognisable in antimicrobial resistance as a public health problem.
Table 1
Rittel and Webber's description of properties of wicked problems (9).
| |
Properties of wicked problems |
Relevance for antimicrobial resistance |
| 1 |
There is no universal definition of the problem. |
Resistance problems are found in various areas (antibiotics, antivirals, antimycotics), and microbiologists and clinicians often have different understandings of the concept of resistance. The definition depends on the microbes, drugs and infections in question. |
| 2 |
The problem has no defined end point. |
Resistance arises spontaneously through genetic changes in microbes, and resistance to new and future antibiotics is therefore also likely to develop. |
| 3 |
Possible solutions are not right or wrong, but good or bad. |
Most of the measures against microbial resistance are not emphatically right or wrong. Many measures will entail both positive and negative consequences that need to be balanced against each other. |
| 4 |
Possible solutions cannot be tested in advance to assess their effects. |
Antimicrobial resistance impacts numerous areas in the health services and society in general, making it impossible to predict all consequences in measures. |
| 5 |
All attempts at solving the problem produce effects that may give rise to irreversible consequences. |
Each measure entails opportunity costs (the cost of not having invested in alternatives) and often affects large groups of patients and inhabitants.
If the effects have a negative health impact, their effects cannot be corrected later. |
| 6 |
There is no well-defined set of possible solutions to the problem. |
We do not have a full overview of the consequences of antimicrobial resistance for different groups and communities. We are therefore also unable to assess possible alternative solutions in a unified manner. |
| 7 |
Every wicked problem is essentially unique. |
Antimicrobial resistance is often compared to other societal challenges such as global warming or overfishing, but the solutions proposed for these analogies cannot be transferred to the resistance problem. |
| 8 |
Every wicked problem can be considered to be a symptom of another problem. |
The development of antimicrobial resistance is often a result of other problems, such as overuse of antibiotics, poor access to health services or insufficient infection control. The problem of resistance is unlikely to be solved without addressing these challenges. |
| 9 |
There are multiple explanations for the same problem. |
Antimicrobial resistance can be described in many different ways that all point to different solutions, e.g. as a health problem, a collective-action problem or as the result of insufficient access to drugs and reliable diagnostics. |
| 10 |
Decision-makers cannot be wrong without affecting the population. |
Antimicrobial resistance is the cause of considerable mortality and morbidity. Decisions to prioritise some measures above others will entail immediate consequences for life and health in different segments of the population. |
The more we discuss the required measures, the clearer it becomes that the current response is insufficient to solve the problem
The theory of 'wicked problems' appears intuitive, but may well be criticised for being purely descriptive (11). It is obvious that the more complex the problem, the more difficult are the decision-making processes, but this insight is not very suitable for identifying the best possible course of action. The question is therefore whether classifying antimicrobial resistance as a 'wicked problem' has any value. The answer to this problem is two-fold. First, Rittel and Webber's categories are useful for highlighting some of the problems that antimicrobial resistance presents to political decision-makers (Table 1). Second, its categorisation as a 'wicked problem' is insufficient, because antimicrobial resistance falls into the category of 'super wicked problems' a group of even more complex societal challenges that were introduced in the discussion on global warming (12). 'Super wicked problems' have four further properties (13) that make them especially intractable, all of which are relevant to antimicrobial resistance (14):
i) The time available for solving the problem is running out. Antimicrobial resistance is a rapidly growing problem, and since few new antibiotics are being developed, there is a risk that bacterial infections will no longer be treatable.
ii) Those who are responsible for solving the problem are themselves contributing to its causes. Many professionals who are working to reduce the effect of antimicrobial resistance are themselves responsible for the use of antibiotics. They may therefore be biased when it comes to their own responsibility. The industry that will be charged with the development of new antibiotics is also responsible for the marketing of antibiotics in many countries. In recent years, the pharmaceutical industry has largely stopped investing in new antibiotics and reduced their production of old antibiotics (15).
iii) Key actors who are charged with addressing the problem have either a weak mandate or no mandate at all. A lot of the efforts to combat antimicrobial resistance must be undertaken at the national level, for example through the establishment of surveillance and effective infection control, or through restrictions on the access to antibiotics without a prescription. This is a challenge for many low and middle-income countries. Moreover, coordination of international activities, such as shared monitoring systems, is difficult without sufficient funding. International organisations have been provided with more support in recent years, but they are still insufficiently staffed to be able to help all member states meet their needs.
iv) Political actions discount the future in an irrational manner. Even if we are not convinced that up to ten million people will die from infections caused by antibiotic-resistant microbes in the future, we need to recognise that the current level of investment is insufficient to implement the recommendations from WHO. The consequence will be an exacerbation of the situation in terms of resistance, and thus a greater global burden of disease.
By describing antimicrobial resistance as a 'super wicked problem', we underscore the need for quick, comprehensive and sufficiently funded action. The categorisation is both normative and a guideline for action (11), but this is not the only relevance of this concept. Understanding antimicrobial resistance as a 'super wicked problem' also entails consequences for the choice of strategy we make to face up to this challenge.