Antibiotic Resistance

Before scanning, we make the stakes legible by naming what silently depends on working antibiotics:

• Routine surgery (every incision risks infection).
• Cancer chemotherapy (immunosuppression).
• Childbirth (sepsis was a leading maternal killer pre-antibiotics).
• Organ transplant, neonatal intensive care, diabetes care (wound infection), and more.

AMR isn't only "infections get harder to treat." It's "the floor under modern medicine softens." Framing it this way changes who should care — it's not an infectious-disease niche; it's everyone who might ever have an operation.

Try it yourself

Before scanning a slow-burn risk, list what *silently depends* on the
thing being eroded. The dependency list reframes the stakes and widens
the set of people the issue concerns.

H1 — The antibiotic-abundance era (fading)

• Broad-spectrum antibiotics cheap, abundant, prescribed liberally ("just in case").
• Heavy agricultural use — antibiotics as growth promoters and prophylaxis in livestock (a major resistance driver).
• A near-empty new-antibiotic pipeline: low prices + short courses + "use sparingly" guidance make antibiotics commercially unattractive — the incentive is inverted versus most drugs.
• The cultural reflex: infection = take antibiotics, problem solved.

Signs of strain:

• 39M directly-attributable AMR deaths forecast 2025–2050; MRSA, Gram-negative resistance rising. (1)
• Last-resort antibiotics (carbapenems, colistin) failing more often.
• Untreatable cases appearing in routine settings.

H3 — A post-broad-spectrum world (emerging)

• Diagnostics-first medicine: rapid point-of-care tests identify the pathogen and its resistances before prescribing, ending empirical broad-spectrum use.
• Narrow-spectrum and precision antimicrobials that spare the microbiome.
• Bacteriophage therapy — viruses that target specific bacteria — at scale, personalised, regulated. (2)
• Vaccines preventing the infections that would have needed antibiotics.
• Microbiome stewardship as routine clinical practice.
• Drastically reduced/eliminated agricultural antibiotic use.

H2 — The contested middle

• Rapid diagnostics. H2+ — shifts the whole logic from empirical to targeted; the keystone enabler of H3.
• Phage therapy. H2+ — but regulatory frameworks (built for static small-molecule drugs, not evolving viruses) are the bottleneck.
• "Pull" incentive models (subscription / "Netflix" payment that de-links revenue from volume; UK's model, the proposed US PASTEUR Act). H2+ if they fund genuinely novel classes; H2− if they just prop up me-too drugs.
• Agricultural-use bans. H2+ structurally, politically hard.
• AI-designed antimicrobials. H2−/H2+ — could refill the small-molecule pipeline (extends H1) or enable novel mechanisms (opens H3).
• Over-the-counter access / weak stewardship in many countries. H1-reinforcing — the global commons problem: stewardship in one country is undone by access elsewhere.

The Three Horizons discipline: the same innovation is H2− or H2+ depending on whether it props up the broad-spectrum-abundance logic or shifts to the diagnostics-first, precision logic. AI drug discovery that refills the broad-spectrum shelf is H2−; the same AI designing narrow, microbiome-sparing agents is H2+.

Try it yourself

Map AMR in Three Horizons.
- H1: the antibiotic-abundance system + signs of strain
- H3: the post-broad-spectrum world (diagnostics-first, phages,
  vaccines, microbiome stewardship)
- H2: contested innovations (rapid diagnostics, phage therapy, pull
  incentives, ag bans, AI discovery), each labelled H2− or H2+
For each, name what flips it — usually the logic it serves, not the tech.

We generate one 2050 per archetype. Each gets a name and a test: what is a routine hip replacement like in this world? (A good probe because elective surgery is the canary — it's only worth doing if infection is controllable.)

Archetype 1 — CONTINUED GROWTH · "Innovation Outruns Resistance"

The official, techno-optimist future. Pull incentives work; a steady drip of new antibiotic classes, plus phages and vaccines, keeps mortality roughly contained. AMR is a managed chronic challenge, not a catastrophe. The system that produced the problem (abundance, weak stewardship) is patched, not transformed. Hip replacement: routine, as today — with a rapid pre-op resistance screen now standard.

Archetype 2 — COLLAPSE · "The Soft Floor Gives"

The pipeline fails to keep pace; resistance outruns innovation; stewardship fragments across the global commons. By 2050, AMR deaths well exceed the GRAM central forecast. Elective surgery contracts; chemotherapy regimens are curtailed; childbirth and routine infections regain their pre-antibiotic danger, hardest in high-burden regions. Medicine quietly retreats to a smaller envelope of the possible. Hip replacement: increasingly refused for higher-risk patients; a "pre-antibiotic" risk calculus returns.

Archetype 3 — DISCIPLINE · "Antibiotic Sobriety"

Society reorganises around treating antibiotics as a precious, exhaustible commons. Strict global stewardship; antibiotics rationed and tightly controlled (prescription-only everywhere, enforced); agricultural use banned; a cultural shift toward "antibiotic sobriety" akin to how some societies came to treat a scarce resource. Constrained, bureaucratic, fairer-if-done-right. The behaviour change is the intervention. Hip replacement: routine, but antibiotics are stringently conserved — narrow-spectrum, short course, justified, logged.

Archetype 4 — TRANSFORMATION · "After Antibiotics"

The antibiotic paradigm itself is transcended. Bacterial infection is managed by a different toolkit entirely: personalised phage cocktails, microbiome engineering, CRISPR-based antimicrobials, immunotherapies, AI-designed anti-virulence agents that disarm rather than kill (reducing selection pressure). "Antibiotic resistance" becomes a 20th-century problem because we stopped relying on antibiotics. Sounds far-fetched — per Dator, that's the point. (3) Hip replacement: routine; infection prophylaxis is a personalised phage patch, no broad-spectrum antibiotic involved.

Try it yourself

Generate one 2050 per Dator archetype:
- Continued Growth — the official "innovation keeps pace" future
- Collapse — the system gives way
- Discipline — society reorganises around conserving the resource
- Transformation — the paradigm itself is replaced
Test each with the SAME concrete probe (here: "what's a routine hip
replacement like?"). Check that at least one archetype sounds
ridiculous.

Insights from holding all four together:

1. The probe exposes the stakes better than the mortality figure. "Elective surgery becomes risk-calculated" (Collapse) lands harder than "1.91M deaths/year," because it shows AMR reaching into ordinary lives, not just statistics.
2. Discipline and Transformation are the neglected futures — and the hopeful ones. Public discourse oscillates between Continued Growth (complacent) and Collapse (fatalist). Dator's value is forcing attention onto Discipline (behaviour/stewardship) and Transformation (post-antibiotic toolkit), which is where agency actually lives.
3. The global-commons structure dominates. Every archetype is shaped by the fact that stewardship is only as strong as its weakest link — resistance doesn't respect borders. This makes AMR structurally like climate: a collective-action problem with free-rider dynamics.
4. The same H2+ technologies appear across multiple archetypes — phages and diagnostics show up in Continued Growth, Discipline, and Transformation. What differs is the system they're embedded in. (This is the Three Horizons insight, confirmed by the archetypes.)

Try it yourself

Read across your four archetypes. Ask:
- Which archetype does the public conversation neglect, and is it where
  agency lives?
- What structural feature shapes ALL four (here: the global commons)?
- Which H2+ technologies recur across archetypes, embedded in different
  systems?

1. What did the two tools together surface? — That AMR's real story is a systems/commons problem, not a drug-discovery problem; and that the neglected archetypes (Discipline, Transformation) are where hope and agency sit.
2. Where did the archetypes flatter or scare you unduly? — Continued Growth is seductive (it requires nothing to change); Collapse is paralysing. Both discourage the harder Discipline/Transformation work.
3. What did you under-scan? — The veterinary/agricultural and environmental (water, soil) dimensions of resistance, which are huge; and the Global South access-vs-stewardship tension (you can't tell people to use fewer antibiotics when many can't get any).
4. What 2026 action does this surface? — Fund pull incentives that target novel classes (not me-too); build rapid-diagnostic infrastructure (the keystone H2+); fix phage-therapy regulation; address the access-vs-stewardship justice tension head-on.
5. What does this refuse? — To predict which archetype arrives. To treat AMR as solvable by innovation alone (it's also behaviour, agriculture, and global justice).

Try it yourself

Reflect in <60 words each: what did the two tools together surface;
which archetype flattered or scared me unduly; what did I under-scan;
what 2026 action follows; what does this refuse to do?

To make a chosen archetype felt, the Design side would build an artifact. From Discipline ("Antibiotic Sobriety"): a 2040 personal antibiotic-allowance record — a controlled, logged, justify-each-course document, like a prescription passport for a rationed commons. Placing it beside a 2026 "take as needed until finished" label would make the paradigm shift visceral. That seeds a Hexagon 2 Design Fiction / Speculative Policy walkthrough (see Topics 4, 11, 13).