26 Sep 2018
– Laurie Denyer Willis – London School of Hygiene & Tropical Medicine

At the beginning of September the AMIS team hosted a one-day Social Science in AMR Symposium at the British Academy. The workshop was funded by the ESRC, as part of the Global Challenges Research Fund. We wanted to highlight the work of early career scholars that are exploring fresh perspectives on the topic of antimicrobial resistance (AMR); who have taken up the challenge of addressing the limitations of an individual behaviour approach to widen the conversation about the entanglement of antimicrobials and life itself. We asked, then, how can social science illuminate the political, economic, historical and social life of AMR? What ways are there to think about and ‘know’ AMR and antimicrobial use? And why do we so often start with individual cognition? How do antimicrobials get deployed to do ‘care work’? What happens if we decentre the human in our analysis, or at least place the human within complex ecologies? This was a moment, then, to come together to think critically about how AMR so often gets framed, and to broaden this via ethnography, history, feminist theory, and socio-political analyses that situate AMR in local and embedded networks, relations, and ecologies.

With this as our platform, the conversations that ensued were incredibly interdisciplinary, including researchers from anthropology, history, geography, science and technology studies, environmental scientists, philosophy and artists. Participants joined us from around the world, representing over 40 countries. We heard about research based in a number of countries, including; the United Kingdom, Uganda, Thailand, Bangladesh, France, Indonesia, China, Mozambique, and Benin.

The symposium was organised into four panels with papers and discussant, a keynote by Steve Hinchliffe, and a final roundtable discussion that aimed to synthesise the day’s conversations, as well as to provide provocations for ways forward for thinking and future research. A summary of critical themes to emerge from each panel is below:

Care:

We began the day by theorising the intersection of care and AMR, with detailed consideration of the ways in which antibiotics often function as a kind of care in contemporary life, and what kinds of ‘caring’ unfold when we isolate AMR at an individual behavioural level. Here, we heard from the anthropologist Katharina Rynkiewich on the neoliberal assumptions that have come to underwrite prescription practices in AMR stewardship projects, and what this means for care practices in hospitals. Artricia Rasyid, based on detailed ethnographic work in Indonesia, explored the ways that amoxicillin signals and enacts modernity, and how physicians give amoxicillin as a care token that is meant to acknowledge inequitable health systems. Meixuan Chen further complicated the binary of rational/irrational antibiotic prescribing through her work in rural China, where physicians must balance pressing immediate need with the seemingly amorphous and distant threat of AMR. The geographer, Mike Kesby, asked us to consider the complexities of what a true interdisciplinary approach to AMR might entail, arguing “that the challenge is not just in addressing ‘the social’ in AMR, but in attending to the genomic and pathogenic in ‘the social’”.

Ecologies:

The second panel of the day brought together a collection of papers that aimed to decentre ‘the human’ in AMR research, training our attention instead to the complex ecologies that AMR unfolds within. Stephanie Begemann, a sociologist, spoke about the need to see antibiotic use in the UK dairy industry “as a practice beyond behaviour”, situating antibiotics within an intertwined network of farm, farmer, veterinarian, environment and animal life. Miriam Kayendeke spoke on the role of antibiotics as a kind of infrastructure in poultry and piggery farms in suburban Kampala where the temporality of farming is being sped up under neoliberal market reforms. The historian Claas Kirchhelle demonstrated the value of revisiting antibiotic history in understanding and responding to AMR. Our attention was drawn to the ways antibiotics have been promoted throughout the past 100 years – entangled with what it is to be modern, in bigger and faster farming, and life and food purified from microbes. And Claas provoked discussion about the exporting of this efficiency model around the world. Richard Helliwell then explored how ‘the environment’ comes to be imagined and enacted – through imaginaries such as ‘reservoirs’, ‘hotspots’, ‘fluidity’ and ‘pristine’ – and what this means for how antimicrobials, and resistant strains and their genes, are either made visible or obscured.

Pharmaceuticals & Markets

The third panel brought together a group of scholars connected via an attention to how pharmaceutical markets – global, local, and in between – shape AMR, advancing the theorisation of antimicrobials as embedded in political, economic and global financial systems. Here we heard from Carla Rodrigues on self-medication with antibiotics via ‘home pharmacies’ in Maputo, and the ways that social relations, access to markets, and the trustworthiness (or not) of providers all play a role in what is deemed ‘appropriate use’. Panoopat Poompruek spoke to the on-the-ground realities of enacting global ‘rational’ antibiotic use strategies in local health facilities in central Thailand, how certain diseases and illnesses are emerging as target areas for antibiotic overuse, and how physician behaviour, unlike patient behaviour, was imagined as too difficult to change. Nicolas Fortané’s research situated the work of global markets in shaping professional veterinary services, opening a way to think through the explicit connections between the development of veterinary expertise in sync with the very specific needs and market demands of industrial poultry and pig production in western France. Here, Fortané positions “the emergence of the veterinarian as an integral part of a global supply chain ensured the healthy management of not just pigs, but of a national economic sector”.

Knowledge:

The final panel of the day extended and deepened our conversation around AMR by focusing on the multiplicity of ways we might conceptualise, or ‘know’, the microbial and our relations with them. Luke Collins presented a detailed linguistic analysis of the ways antibiotics are talked about, for example how the deployment of the passive voice in our discussions of AMR suggests we often frame it is as a way that antibiotics are failing ‘us’. Esmita Charani explored the challenges of antibiotic stewardship, and how to generate knowledge of stewardship programmes that are implemented against a cluttered background of multiple interventions and activities. She introduced a new project that attempts to engage publics about AMR via cartoon. Salla Sariola discussed a vaccine trial that pressed tourists in Benin to rethink the limits and porousness of their bodies in relation to microbes, pathogens, along with the cultural and political spatial relations of tourism and medical research. Finally, Andrea Núñez Casal introduced the room to the concept of feminist para-ethnographies, a “theoretical and methodological proposition for a future of interdisciplinary knowledge practices of co-existence, care and decoloniality” that takes seriously the entanglement of certain lives with certain mircrobes, and the sympathetic and intimate biologies of these relations.

Conclusion:

Broadly speaking, AMR is often figured as an apocalyptic crisis tied to irrational prescribing and consumption of antibiotics, that must be averted via changes to individual behaviour and knowledge. And yet, as this symposium explored, this narrowly linear mode of argumentation is simply unmaintainable when confronted with the rich worlds that antimicrobials occupy. Everyday life is deeply embedded and intertwined with antimicrobials. An antimicrobial is always more than just curative, it is part of an antibiotic infrastructure (Chandler forthcoming) that enables life as many of us have come to know it in a range of ways; intersecting with how we know, how we care, and our ongoing relations with complex ecologies, markets and space. What this symposium has pressed us to do is to reckon with these multifaceted landscapes that AMR unfolds within. Throughout the day, presenters and discussants created spaces for interpreting the ways AMR knowledge and action are co-constructed, and demonstrated how the application of social theory to AMR has the potential to enrichen our repertoire of responses to this complex issue.

In addition, a number of posters were presented, with details available here:

  • Alena Kamenshchikova: Multiple versions of “One Health”: an analysis of policy discourses in international politics of antimicrobial resistance
  • Alexandra Hughes: Corporate food retailers, meat supply chains and the responsibilities of tackling- antimicrobial resistance (AMR)
  • Andrea Butcher: Aquaculture Ponds in Ontological Refraction
  • Anna Silvia Voce: Realist review of IPC measures: A conceptual framework for extraction of data from multiple disciplinary perspectives
  • Carolyn Tarrant: Antimicrobial stewardship: a principal-agent problem?
  • Chawanangwa Mahebere Chirambo: Roles of antibiotics in Fever Management in Chikwawa, Malawi
  • Christine Nabirye: Exploring antibiotic use in an urban informal settlement among daily wage earners in Kampala District, Uganda
  • Christopher J Colvin: Nosocomial Transmission of DR-TB as a Contested Object of Policy Knowledge in the Development and Implementation of DR-TB IPC Policy in South Africa
  • Emma Roe: Mapping Microbial Stories: creative microbial aesthetic and cross-disciplinary intervention in understanding nurses’ infection prevention practices.
  • Gisle Solbu: Antimicrobial resistance research and the making of a Norwegian bio-economy
  • Justin Dixon: Rethinking “Ordinary Fever” in Global Health: Algorithms and Classification Work in an Era of Antimicrobial Resistance
  • Kristen Overton: A sociological study on antimicrobial use and resistance in India
  • Maddy Pearson: Tinker, Tailor, Soldier, Sailor: Contextualising Antibiotic Prescribing and Dispensing across Low-Middle Income Country settings.
  • Marco Haenssgen: Antibiotics and Activity Spaces: An Exploratory Study of Behaviour, Marginalisation, and Knowledge Diffusion
  • Nichola Naylor: Eliciting societal decisions regarding antimicrobial consumption: can health economic methods help?
  • S M Murshid Hasan: An anthropological exploration of antimicrobial use among commercial poultry farmers in Bangladesh: a study protocol
  • Susan Nayiga: Consequences of the imperative to restrict antimicrobial medicine use in Uganda: what is health care when antimalarials and antibiotics are under threat?
  • Zane Linde-Ozola: Microbiopolitics of human-microbe relationships: fight against hospital superbugs in Latvia
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