14 Nov 2018
– Laurie Denyer Willis – London School of Hygiene & Tropical Medicine

In September 2018 the AMIS Programme hosted a symposium to highlight the work of early career scholars that are exploring fresh perspectives on the topic of antimicrobial resistance (AMR). Presentations that were filmed, including a keynote from Stephen Hinchliffe (University of Exeter), are available below.

Mike Kesby (University of St Andrews): Seeking UTI care ‘that works’ in Uganda: work in progress

Antimicrobial resistance demands an interdisciplinary response that draws insights from both biomedical and social science. But this is the easy part: work across disciplinary boundaries is often less problematic than communication across epistemological ones. Moreover, the challenge is not only to attend to ‘the social’ in AMR, but also to attend to the genomic and pathogenic in the social. Perhaps ‘new materialism’ offers a single epistemological perspective from which to explore assemblages of human and non-human actants, material objects and flows, and discourses and practices. Again, this is the easy part: how to design research programs where qualitative and quantitative, and social and medical data are collected synergistically and analyse integratively? This paper begins to address these issues by drawing on pilot data from the HATUA project (an international, interdisciplinary study of the drivers of AMR in Urinary Tract Infections in three East African countries). Focus group respondents from diverse communities describe complex health-seeking behaviours that move back and forth between folk, popular and professional sectors, and proscription, self-medication and drug experimentation. In the context of limited resources, AMR, and unregulated pharma, care ‘that works’ emerges from a complex of bio-social interactions.

Stephanie Begemann (University of Liverpool): Antibiotic policies in the UK dairy industry: unravelling the practices behind the numbers

This PhD has used a qualitative study design to explore how the UK dairy industry develops and implements antibiotic policy, and how this impacts on dairy antibiotic use as public health risk. A multi-sited ethnographic has been used which involved a policy document analysis, in-depth interviews with key dairy stakeholders, participant observation of veterinarians in practice and the observation of policy transfer during farmer meetings from retailers to farmers. Adopting a Science and Technology theoretical framework, fieldwork results indicate that antibiotic policies in the UK dairy industry only partially address the complex network of people, animals and the environment in which antibiotics circulate. Although UK milk processors and UK retailers have taken up the lead to produce dairy antibiotic policies, the policies are fragmented and seem to rather benefit market purposes than address structural issues in UK dairy production systems. At the same time, the policies fail to assess the complex interplay of antibiotic exchange between veterinarians and farmers. Hence, if we want to reduce the human health risks of agricultural antibiotic use, we need to evaluate agricultural antibiotic practices beyond the achievement of antibiotic reduction targets.

Miriam Kayendeke (Infectious Diseases Research Collaboration): Assessment of the use of antibiotics and its social context on poultry and piggery farms in Wakiso district, Uganda

Antimicrobial resistance has become a global public health priority. The use of antibiotics in food-producing animals is closely related to those used in human medicine and have been reported to select for resistance in these animals. Antimicrobial resistance (AMR) policy meant to reduce antibiotic use is largely based on individual behaviour change theory, yet these individual approaches are inadequate at explaining why antibiotics are widely used in animal husbandry. This study seeks to explore how antibiotics used in animal husbandry are understood within the wider social and economic context in Uganda. The study will employ rapid ethnography observations on a pig and poultry farm teasing out the role antibiotics play role to the farmer’s livelihood, daily care and health provision in poultry and piggery husbandry. In depth interviews will be held with farmers and feed sellers exploring antibiotic use in the context of daily farm life. The results will provide useful information about the antibiotics used a in social and economic context. This shall inform interventions at the micro and macro level to reduce reliance on antibiotic medicines and improve use.

Claas Kirchhelle (University of Oxford): Pharming Animals – antibiotics in global food production (1935-2013)

Since their advent during the 1930s and 1940s, antibiotics and sulphonamides have not only had a dramatic impact on human medicine but also on food production. On farms, whaling and fishing fleets, and in food processing, antibiotics were used to treat and prevent animal and plant disease, increase feed conversion, and preserve food. Their rapid diffusion into nearly all areas of food production and processing was initially praised as a story of scientific progress. However, from the late 1940s onwards, agricultural antibiotic use has also given rise to continuous conflicts about drug residues, antimicrobial resistance (AMR), and antibiotic-facilitated animal welfare abuse. Perceptions of and solutions to antibiotic hazards have differed significantly. This presentation reconstructs the global history of antibiotic use, perceptions, and regulations from the 1930s onwards. By comparing the rise and evolution of different antibiotic infrastructures, it examines why the regulation of antibiotics differs internationally. It also shows that the development of effective antibiotic stewardship requires an historical understanding of the deep-rooted cultural, social, and economic factors driving drug consumption and fragmenting risk perceptions.

Richard Helliwell (University of Nottingham): Making chemical infrastructures (in)visible: Environmental Imaginaries and the environmental sciences of antimicrobial resistance

Positioned as representing hope that human life can flourish in the face of pathogenic life, paradoxically the use of antimicrobials has also come to represent a threat to their future efficacy. Once susceptible microbes have become resilient to the toxic effects of antimicrobials and are becoming significant problems in human health care settings. However, AMR is not only centred on its impacts on diseased bodies, but also includes the environment. The ‘environmental dimension of AMR’ engages with questions regarding antimicrobial agents within environmental systems, their impacts on microbial communities and their implications for human health outcomes. In investigating these questions, the field enacts culturally specific forms of imagining the environment which shape the practices and places through which antimicrobials, resistant microbes and genes are made visible, while effacing others. This paper investigates what environmental imaginaries are evident in environmental AMR research, and how they are shaping the practices and places through which environmental sciences attempt to make visible antimicrobial pollutants, resistant bacteria and genes. In doing so we draw attention to the tensions between an imagined, flattened and global environment, and the environment as encountered through scientific practices, which reveals the uneven spatial and temporal distributions of chemical infrastructures.

Md Fosiul Alam Nizame (International Centre for Diarrhoeal Disease Research, Bangladesh): Perspectives of ‘unqualified’ practitioners on antibiotics in Bangladesh

In the context of the global emerging antimicrobial resistance (AMR) crisis, Bangladesh is particularly vulnerable due to unregulated and ‘irrational’ use of drugs within the large informal health sector. There are more than one‐hundred thousand unlicensed retail drug shops involved in selling drugs over‐the‐counter. The current study explored the knowledge and practice of antibiotic provision among ‘unqualified’ drug sellers in rural and urban areas. The study used various qualitative research methods. The preliminary results show that knowledge and practice varies greatly among untrained drug sellers ranging from gross ignorance about antibiotics and rational use due to limited current knowledge and responsible practice. The study also revealed that the drug sellers have developed certain local vocabularies about antibiotics, such as ‘half‐antibiotic’, ‘full‐antibiotics’, ‘medicines of power’, ‘disease remover’. The majority understood drug resistance as a ‘side effect’ of antibiotics. Using the theory of ‘Social Lives of Medicines’ this paper argues that the unqualified drug sellers have a significant role in the biographies of antibiotics in Bangladesh and their misunderstandings about antibiotics therefore can contribute to the rise of AMR. The study findings have been used to develop communication materials to improve the rational dispensing of antibiotics.

Panoopat Poompruek (Silpakorn University): Rational use of antibiotics in Thailand: realities from local health facilities in central Thailand

In Thailand, Rational Drug Use-RDU Policy has been launched since 1981. Throughout years of implementation, achievements were hindered by a lot of barriers. However, in the recent Five-Year National Drug Development Plan (2012-2016), RDU was one important national strategy. In 2014, one strategic move was the implementation of national Rational Drug Use Hospital- RDU Hospital under collaboration of many concerned authorities including MoPH, National Health Security Office, Medical School Network Consortium etc. This paper relies on an exploratory ethnographic fieldwork which is part of a collaborative project on anthropological study of antimicrobial resistance in Thailand- AMIS. Highlights of this paper, basing on qualitative interview and observation in a community hospital, health centre and households, are that, although the RDU policy has been clearly advocated, 1) rational use of antibiotics for URI, acute diarrhoea, fresh traumatic wound and vaginal delivery of term labour was enforced, 2) the implementation was restrained by both provider/supply and user/demand sides, 3) doctor’s power and professional freedom as well as unreadiness of lab facilities and hospital beds failed the hospital in following the RDU standard procedure, 4) popular beliefs and expectations of the patients led to strong demand for and pressure to health care providers to give antibiotics especially at the health centre, 5) antibiotics are widely and easily accessible especially from local pharmacies, private clinics and hospitals. The interaction of these contextual factors is found pushing the success of the RDU policy implementation away from the goals set.

Nicolas Fortane (INRA – French Institute for Agricultural Research): The evolution of the veterinary drug market and antibiotics prescribing practices of French veterinarians

In France, the re-emergence of the public problem of AMR in livestock at the end of the 2000s largely focused on the supposed conflict of interest of veterinarians, who have a monopoly on both prescription and delivery (and therefore sale) of antimicrobials. Although this monopoly has been safeguarded thanks to intense political lobbying by the profession, various policy measures have been adopted to better regulate the veterinary drug market, in particular the conditions under which antimicrobials are prescribed and sold. In fact, by promoting a change in the business model of veterinary practices (income structure less dependent on the sale of medicines), these measures encourage a transformation of the knowledge and working conditions of veterinarians whose roots are older. Preventive veterinary medicine, which generally consumes less antibiotics, has its origins in the intensification of pig and poultry farming in the 1980s, which encouraged the development of epidemiological approaches and franchised veterinary practices whose services offer (and therefore income structure) are more diversified. On the other hand, recent policy measures tend to generalize this model of veterinary medicine, which until then was confined to a very specific segment of the profession, but which could rapidly become dominant. This work is part of a research project on the evolution of the French veterinary drug market and is based on some thirty sociological interviews with poultry and pig veterinarians in western France.

Luke Collins (Lancaster University): Who or what has agency in the discussion of antimicrobial resistance in the UK news media (2010-2015)?

The increase in infections resistant to the existing antimicrobial medicines has become a topic of concern for health professionals, policy makers and publics across the globe; however, among the public there is a sense that this is an issue beyond their control. Research has shown that the news media can have a significant role to play in the public’s understanding of science and medicine. In this article, we respond to a call by research councils in the United Kingdom to study antibiotic or antimicrobial resistance as a social phenomenon by providing a linguistic analysis of reporting on this issue in the UK press. We combine transitivity analysis with a social representations framework to determine who and what the social actors are in discussions of antimicrobial resistance in the UK press (2010–2015), as well as which of those social actors are characterised as having agency in the processes around antimicrobial resistance. Findings show that antibiotics and the infections they are designed to treat are instilled with agency, that there is a tension between allocating responsibility to either doctors-as-prescribers or patients-as-users and collectivisation of the general public as an unspecified ‘we’: marginalising livestock farming and pharmaceutical industry responsibilities.

Esmita Charani (Imperial College London): Exploring the use of animation to promote the role of social science research as a tool for engagement with healthcare professionals on antimicrobial stewardship

Aims: Investigating animation as a platform to promote and communicate social science research findings amongst healthcare professionals (HCP). Methods: We have co-developed scripts with country collaborators and healthcare professionals based on findings of two social science research studies. Through a competitive process two animation companies were invited to develop animation wireframes. Results and next steps: One animation based on implementation of antimicrobial stewardship across five countries (England, France, Norway, India, Burkina Faso) has been developed with Beluga Animation and tested on a group of HCP. Using the feedback, the animation is in post-production editing stage to develop an engaging narrative. The second animation is being developed with award-winning company, Second Home Studios and will be a short effective summary of an ethnographic study investigating differences in antibiotic prescribing between medical and surgical teams. Using two different animation companies enables us to test different media and provide learning in how animation and storytelling can be used to disseminate social science research findings. The final animations will be shared with HCP across participating countries through social media and networks. Impact will be measured using video analytics e.g. watch-time, traffic source and views. A question-time style event with HCP will be held showcasing the animation and generate debate on key findings. The animation will be demonstrated at the ESRC symposium.

Salla Sariola (University of Helsinki): Living-with Microbes in the Era of Antimicrobial Resistance: International Vaccine Development in Benin, West-Africa

The rise of anti-microbial resistance has pushed for the development of various forms of new health care technologies that aim to circumvent the use of antibiotics. This paper explores a vaccine study in Benin, West Africa, that aims to prevent bacteria-borne diarrhoea and the development of drug resistant strains. The vaccine is a new technology in the post-antibiotic era that follows the logic that as diarrhoea presents a risk for acquiring AMR, preventing diarrhoea protects also from acquiring AMR. The paper analyses global circulation of AMR through an ethnographic case study of encounters between North European tourists, who double-act as participants in the vaccine trial, with local populations of Grand Popo, Benin. As part of the vaccine trial, the tourist-cum-research volunteers spend two weeks in the region chosen for its moderate levels of infectious diseases and antimicrobial resistance as well as historical, cultural significance. While holiday-making in Benin, these study participants become exposed to various new bacteria; some fall ill with diarrhoea, while other don’t. In this encounter, social and microbial cultures meet and mingle. Based on research conducted in 2017-2018, paper seeks to understand how all those involved in the trial understand microbes and anti-microbial resistance. Their experiences in the vaccine study reveal the different modes of discussing, embodying, embracing, and resisting encounters with ‘the local’, both human and microbial. The paper discusses the shifting ways the tourists embody and discuss their bodily contours and assumed embodied integrity, porousness and fragility, in relation to their environments.

Andrea Nunez Casal (Goldsmiths, University of London): Birthing antimicrobial resistance: Feminist para-ethnographies as interdisciplinary care knowledge practices

In this paper, I ask: Is it possible to develop a ‘critical friendship’ (Rose, 2013) between the social sciences and humanities and the life sciences in order to find alternative solutions to AMR? In response to this question, I engage with decolonial literature on Buen Vivir (De La Cadena, 2010; Gonzalez and Macias Vazquez, 2015; Gudynas, 2011; Harding, 2016; Lanza, 2012; Leon, 2012; Walsh, 2010) and feminist debates on care and care practices (Bellacasa, 2011, 2012; Martin, Myers, Viseu, 2015; Mol, 2008). I develop what I call ‘feminist para-ethnographies,’ an intersectional method that entangles embodied experiences of AMR and antibiotic use with ethnography and ‘fugitive’ qualitative data in technoscientific claims (Nading, 2016). I propose feminist para-ethnographies as an interdisciplinary and biosocial method to tackle both antibiotic overuse and AMR through the realisation of what Denise Riley calls ‘socialised biology’ (Riley, 1983), which refers to biology “lived within particular lives” (ibid: 40). Feminist para-ethnographies is a critical method that records, documents and provides situated accounts of embodied biological experience. It complements what ‘evidence-based biomedicine’ fails to register and see. In sum, Feminist para-ethnographies figures as a theoretical and methodological proposition for a future of interdisciplinary knowledge practices of co-existence, care and decoloniality.

Keynote: Stephen Hinchliffe (University of Exeter): The AMR Problem: Demanding ecologies, margins and co-producing alternative strategies