Social science has much to offer in addressing AMR. The AMIS programme asks fundamental questions about the role of antimicrobials in society and explores fresh approaches to studying it.

Drawing on conceptual and methodological tools from anthropology, we hope to demonstrate the multiple roles that antimicrobials take in society today, and how they enable everyday life.

The following themes draw together some of the bodies of work in the social sciences that are relevant to AMR.  We will expand on our research themes over the lifetime of the AMIS programme, as our appreciation and understanding of the role of antimicrobials in society continues to grow.

Care

Antibiotics often take the form of care in contemporary life. They are objects that ‘care’ for our sick and vulnerable. Giving antibiotics, then, is often a central way that caregivers perform their care.

Antibiotics often take the form of care in contemporary life. They are objects that ‘care’ for our sick and vulnerable. Giving antibiotics, then, is often a central way that caregivers perform their care.

From a physician with limited time for a patient, to a parent with a sick child running out the door to work, or even the humanitarian necessity of bestowing affordable pharmaceuticals on the developing world, antibiotics are a central part of how we give and receive what we think of as ‘good care’.

We often assume that care decisions around antimicrobial use happen in the clinic, between physician and patient. Research demonstrates, however, that globally these care decisions most often occur outside of the clinic, within families, informal ‘drug shops’, or social networks. Mark Nichter’s (2001) ethnographic research in the Philippines, for example, provides a rich description of preventive and protective antibiotic use by patrons of sex workers, who variously took antibiotics before sex, after sex, occasionally or routinely depending upon their own situations and familiarity with the particular sex worker. His analysis demonstrates how the use and care around antibiotics is made within the context of vulnerability, stigma, and perceived harm-reduction.

In anthropology, we say then that care is situated and contextual. This means that we can’t take for granted people’s reasoning, and instead we need to consider the wider picture: What are the particularities, immediate details, socioeconomic or cultural factors behind a certain care decision or form of antibiotic use? A decision about antibiotic use, sex work and sexually transmitted infections is not a singular problem of seeking out the right treatment, but involves a careful consideration of desire for anonymity, gender norms and/or individual safety. The anthropologist Arthur Kleinman has further elaborated on how the context of care shapes the meaning of medicines for both providers and patients. Kleinman’s professional, folk and popular sectors model demonstrate how different social relations as well as clinical realities are key characteristics in use of medicines (Kleinman 1980).

While ‘rational use’ has defined the majority of policy undertakings over the past few decades, anthropologists are providing evidence of consumers’ own rationalities for use of medicines and care decisions. It is easy to fall into the trap of casting these behaviours as ‘misguided’, but by highlighting the institutional, ethical, and everyday forms of care that hinge on antimicrobial use (and vice versa), we open a space to think differently – about care and its contexts. How do the contexts of care shape our interpretation of antimicrobial resistance (AMR).

Ecologies

AMR requires us to open our research agenda to think about the ways human life is entangled with microbes, animals, plants and the environment. AMR poses tricky questions about human exceptionalism and pushes us to consider how we begin to study our human interactions with - and within - complex ecologies.

AMR requires us to open our research agenda to think about the ways human life is entangled with microbes, animals, plants and the environment. AMR poses tricky questions about human exceptionalism and pushes us to consider how we begin to study our human interactions with – and within – complex ecologies.

Our relationships, for example, with our animals – from pets to livestock – bring us into contact with the microbial worlds inside these animal companions. Seemingly mundane questions about how we care for animals, where they sleep, whether we consider them family or food (or both), and what we choose to inject them with, are all components that shape our entanglement with the microbial world and the conditions of antimicrobial resistance (AMR) today.

Social scientists working in the field of biosecure farming, for example, detail the ways that farmers actively work with, rather than against, complex microbial environments, in the ‘making of safe life’ for pigs and humans. Hinchliffe and Ward (2014) outline the kinds of situated knowledge and practices that vets, breeders and farmers deploy in order to raise healthy pigs, and how this in-depth knowledge is “obscured and even endangered when biosecurity is reduced to the simple protection of disease-free livestock” (136).

This approach in anthropology is often called ‘multispecies ethnography’. It is an approach that aims to de-centre the human and instead, prioritize entanglements of human, animal, microbial, and environmental landscapes. In other words, we must take the lives of other species, besides humans, seriously. In doing so, multi-species ethnography seeks to contribute to better understanding how we live with and against other species (e.g. mammals, insects, fungi and microbes), their relations with humans, and the ways that economic, political and cultural processes shape our lives together.

Drawing on the multispecies literature and some of the concepts it offers, will provide fruitful avenues for studying the many ways that antimicrobial resistance comes into being, is spread, and the multiple species that may be involved in these processes. Multi-species ethnography offers anthropology of science and interdisciplinary research more broadly, a way to empirically explore the contingency of human-nonhuman-antibiotic-microbe relations in the production and movement of AMR, the specificity of contexts where it arises and the different responses mobilised.

Knowledge

Health practitioners are increasingly observing that knowledge does not equate to practice.What other ways are there to think about and ‘know’ AMR?

Research shows that knowledge about ‘appropriate’ antimicrobial use does not equate to following recommendations in practice for clinicians or patients (Chandler et al 2008; Kamat 2006). Nonetheless, when the global community begins to address an emerging health crisis such as AMR, we start from assessment of knowledge and awareness raising activities (Chandler et al 2015; Yoder 1997). What other ways are there to think about and to come to ‘know’ about AMR and antimicrobial use? And why do we so often start with individual cognition?

Social scientists – like natural scientists – want to push the boundaries of knowledge, asking questions about taken-for-granted concepts and truth claims to demonstrate that what often appears as static, singular and fixed, is typically contingent and dynamic. For example, for antibiotics this might involve asking what constitutes and defines the ‘rational’, ‘irrational’, or ‘prudent’ use of antibiotics in different settings? And asking who gets to define these concepts? Thus, rather than starting with questions about human behaviour in antimicrobial use, we may think more widely about our reliance on antimicrobials on a societal level. This also necessarily requires reflection on scientific practices, policy guidelines, legal frameworks and regulations that AMR unfolds and exists within. Here, science, technologies and policies are studied as processes that contribute to defining, organising and acting on the world in particular ways. To do so, involves paying close attention to how a problem is framed, for example the language and metaphors used (e.g. war) may mirror wider societal concerns (i.e. migration) and can reveal what is at stake for whom. This is exemplified in Brown & Nettleton’s article.

Policy-guidelines and scientific studies often attribute the rise in AMR to individual behaviour of doctors, patients, drug sellers and their customers. This makes sense within behaviour models that locate individual human action at the centre. However, how well these models map on to the materialities of microbial, genetic and antimicrobial ecosystems is unclear. One approach to understanding how we have ended up with particular models of biology is tracing a social history of biology, locating dominant narratives in wider context. For example, we learn in Roberto Esposito’s (2011) Immunitashow entwined our visions of microbial life are with our political histories in Europe, and how this has shaped what we have seen as possible anti-microbial measures. Another approach is to delve further into the details of processes through which AMR has written a biology of history as Hannah Landeker has done, depicting how for example mass consumer culture, differences in access and regulation of antimicrobials, and neoliberal market politics have all been inscribed into the biology of AMR. These examples demonstrate how the careful analysis of the context of the co-construction of science and policy of AMR can open up new spaces for knowledge production.

Phamarceuticals and Markets

There are stories behind the ways we use antimicrobials across the world today. These are not only stories of medical science or of happenstance but also of economics and politics.

There are stories behind the ways we use antimicrobials across the world today. These are not only stories of medical science or of happenstance but also of economics and politics.

The presence of carbapenems in grocery shops in India can be understood as a story not only of local markets or supply and demand, but also a story of ‘pharmaceuticalisation’ and global ‘individualisation’ of the self. Tracing the multitude of contexts within which antimicrobials are prescribed, sold, and traded involves exploring the nature and scale of markets as shaped by specific histories and political economies.

On a local scale, anthropologists have produced over the past four decades a substantial body of work on the flow of antimicrobials through informal spaces including ‘drug shops’, through social networks, and via experimentation outside the lab on farms and in homes. These informal channels are often denigrated as dangerous peddlers of antibiotics and information, but these sources of care have been shown to have important functions in fragmented health systems (Whyte, Van der geest and Hardon 2002). Furthermore, the distinction between ‘informal’ and ‘formal’ is often blurred. For example, patients often seek treatment from those on the ‘edges of legitimacy’ (Pinto 2004), and formal pharmaceutical companies often rely on ‘informal’ shops to sell their antibiotics where formal channels are tricky to access.

On a global scale, antimicrobials operate within the business models of the multinational pharmaceutical industry. Anthropologists have written extensively on the ways in which the operationalisation of these modesl has shaped approaches to disease and health. For example, one of the unintended consequences of scaling up international action on health – from malaria to HIV/AIDS treatment – has been observed as “the consolidation of a model of public health centred on pharmaceutical distribution” (Biehl, 2007:84) rather than prevention and/or clinical care. For many in the Global South, while pharmaceuticals are becoming more widely available, it can still be impossible to actually see a physician when visiting a public health clinic. Many social scientists now refer to this shift in health delivery as the ‘pharmaceuticalisation’ of public health (Biehl 2007, 2013; Petryna et al. 2006; Lakoff 2005; Oldani 2004).

The concept of pharmaceuticalisation emerges from the related term medicalisation, which can be understood as the encroachment of biomedicine into areas of life hitherto considered in the domain of the social, such as childbirth. Both concepts represent processes through which the context of health and care can be stripped away; through which political, economic, and social determinants of health and of care are obscured by approaching disease and treatment in exclusively biomedical terms (Biehl 2004, Conrad 2007; Davis 2009; Scheper-Hughes 1992). In addressing AMR, the concept of pharmaceuticalisation is useful to consider in orienting questions around the consequences of AMR, and of reducing our reliance on antimicrobials.

What is striking about AMR is that by indicating the overuse of medicines, it brings to the fore how pharmaceuticalisation has largely gone unchallenged. Yet, rather than disrupting pharmaceuticalised forms of care that rely on antibiotics to manage health, much of the AMR discourse enlivens pharmaceutical markets. AMR campaigns emphasise the centrality of pharmaceuticals in healthcare, rendering them even more desirable. Policy typically encourages investment in new kinds of antimicrobial medications, as well as other complementary technologies of rapid diagnostic testing, and laboratory upgrading.

Anthropological research, then, has attempted to situate medicines as they are prescribed, sold, and traded within local networks of relations embedded in particular histories, legacies and political economies.