Paper short abstract:

This paper first provides an overview of AMR regulations launched by Chinese national and Provincial health authorities in the past two decades and then examines how and why when these top-down official initiatives are translated into local practices they have not achieved the intended outcomes.

Paper long abstract:

Antimicrobial resistance (AMR) has been identified as an issue of global and national significance in Public Health. In this paper we discuss why AMR policies in China have failed to be effective. We draw on over 60 semi-structured interviews and observations conducted in 3 village clinics and 3 township health centres, examining how rural residents and families access and use antibiotics among other medicines.

This paper has two parts: Part 1 will provide an overview of AMR regulations and policies launched by Chinese national and Provincial health authorities in the past two decades—for example, the List of Essential Medicine, the New Agricultural Co-operative Medical Scheme (NACMS) and other relevant policies.

Part 2 will examine how these top-down official initiatives are translated into local practices in Primary Care rural health facilities and why they have not achieved their intended outcomes. We argue that the infrastructure of modern social-economic life in rural Anhui Province affect residents' health-seeking behaviours, in particular, accessing and consuming antibiotics. Their health-seeking behaviours are closely linked to the values of productivity and time, and the expectation that antibiotic will yield fast and full recovery. Hence, perceptions of the potency of antibiotics is central to both their use and the desired form of administration; particularly the use of "drips" (IV treatment which usually contain antibiotics) for the common cold or flu. The need for a "quick fix" is very much embedded in rural-to-urban migration practices, the intergenerational exchange of care and moral values of reciprocity.

Paper short abstract:

The 'irrational' use of antibiotics is a significant cause of AMR in developing countries including Bangladesh. A qualitative account using the theory of 'Social Lives of Medicines' revealed medical-representatives influence the prescribing and dispensing antibiotics through innovative marketing.

Paper long abstract:

Antimicrobial resistance (AMR), has been acknowledged by the WHO as a serious global public health threat. The 'irrational' use of antibiotics is an important cause of AMR. Like many other developing countries, there is little regulation of drug production, prescription and use in Bangladesh. Unqualified health providers in the informal sector supplement the shortage of qualified health workforce, especially among the poor and in disadvantaged areas. As part of a larger project investigating the pathways of antibiotic use in Bangladesh, this paper explores the role of a specific actor, namely Medical Representatives (MR), for popularizing antibiotics in particular. Key-informant interviews and observations have been conducted with MR and key personnel of various multi-national and national pharmaceutical companies. Our findings revealed, MR influence the prescribing and dispensing pattern of both qualified doctors and non-qualified dispensers through their robust marketing, innovative incentives catering for different health providers, and the symbolic value of their appearance. The theory of 'Social Lives of Medicines' denotes that medicines have lives and that the meaning and use of medicines varies according to the context. The study shows MR of various pharmaceutical companies play a crucial role in interpreting the meaning and use of antibiotics in Bangladesh. This ultimately contributes to the irrational prescribing/dispensing of drugs, which is, in turn, a key contributor to the emergence of AMR. Using Michael Cronin's theory of 'Globalization and translation', we argue, MRs are one of the critical 'translators' of antibiotics that play a major role in antibiotic resistance in Bangladesh.

Paper short abstract:

In spite of intensified global health initiatives, a global epidemic of drug-resistant tuberculosis (DRTB) has developed. Based on ethnographic explorations of multilayered and multispecies resistances driving development and spread of DRTB, I discuss the recently revised strategy to End TB by 2030.

Paper long abstract:

Apart from occasional visits to diagnostic facilities and regular visits to receive treatment, active tuberculosis (TB) disease in India is largely managed with outpatient ambulatory treatment and home care, based on the assumption that a well-treated TB disease is relatively quickly rendered non-infectious. In a context where initial treatment is often pursued in a largely commercial healthcare sector, where sporadic, insufficient and wrong treatment is common, rather than becoming non-infectious the disease may become resistant to first-line treatment and remain infectious. In this presentation, I will explore how a multispecies ethnography approach to the anthropological study of the development of drug-resistant tuberculosis may allow for a focus on multilayered and interrelated resistances across traditional species barriers. Forms of resistance at intracellular levels interact dynamically with resistances to pharmaco-toxicity, commercial exploitation and intersubjective rejection linked to diagnostic and treatment practices; all interlinked with the progression of disease/cure. The empirically informed part of my talk presents insights from ethnographic work-in-progress based on dialogues and other exchanges with people suffering from drug-resistant tuberculosis in India. The presentation discusses the feasibility of the WHO strategy to 'end TB' in view of its recent modifications.

Paper short abstract:

Drawing on 10 months ethnographic fieldwork conducted in Barcelona, this paper explores the circulation and consumption of antibiotics in Spain through the prism of crises in care and capitalism.

Paper long abstract:

Recent historical work on the circulation of antibiotics in Spain during "the long post war years" has described the complex inter-relationships between antimicrobial medications and processes of political and socio-economic transformation. The supply of penicillin reflected the material scarcity and black-market dependency that characterised economic life under the first decades of Franco's dictatorship, whereas the emergence of concerns about antimicrobial resistance (AMR) and the regulatory regimes that followed have been described as agents in the Spanish transition to democracy in the 1970s and 1980s.

In recent years, as AMR has become a priority for global health, the "problem" of antibiotic consumption in Spain has been framed in national media and public health campaigns as a question of scientific rationality versus entrenched cultural norms and ill-informed customs. At the same time however, the international financial crisis that began in 2007 hit Spain hard, resulting in higher levels of unemployment, poverty, and what has been termed a "crisis of care".

Drawing on accounts of medical doctors and residents of Barcelona, this paper explores how the old "miracle drug" continues to promise "quick fix" solutions in an era defined by work precarity and time poverty. We argue that the circulation and consumption of antibiotics in contemporary Spain is animated by crises in capital and care and cannot be adequately understood in abstraction from this broader political-economic context.

Paper short abstract:

By examining the social scientific debates on AMR, this paper examines the assumptions and justifications around the ecology of AMR.

Paper long abstract:

The recent developments in multispecies ethnography continue to shape research projects and policy interventions on antimicrobial resistance (AMR) as a public health priority. The objective here is to reduce the overuse of antibiotics in human and non-human settings. In this paper, we explore what is at stake in the making of knowledge around AMR. The World Health Organisation framed AMR as a question of 'One Health approach'. Scientific approaches to AMR focus on interdisciplinary 'solutions'. At the same time, anthropologists Kathryn M. Orzech and Mark Nichter considered AMR as a problem within the debates on global health (2008). Following microbes (Kirksey and Helmreich, 2010: 555), as an object of anthropological enquiry is challenging both conceptually and methodologically. By examining the social scientific debates on AMR, this paper examines the assumptions and justifications around the ecology of AMR.

Cited works:

Kirksey S. E., and S. Helmreich. 2010. The Emergence of Multispecies Ethnography. Cultural Anthropology, 25 (4), 545-576.

Orzech, K. M., and M. Nichter. 2008. From Resilience to Resistance: Political Ecological

Lessons from Antibiotic and Pesticide Resistance. Annual Review of Anthropology

37, 267-282.

Paper short abstract:

AMR offers the unique opportunity to interrogate human-microbe relationships at a critical juncture, asking: what is the impact of the military metaphor on human/microbe relationships and how might these be imagined differently?

Paper long abstract:

Antimicrobial resistance (AMR) is recognised as an "urgent global threat" (Hancock, 2019), responses to which are often centred in military language and responses. Yet as conventional therapies to 'kill bugs' decline in effectiveness, research increasingly asserts the integral role of microbiome in human health. I argue that this tension offers a unique opportunity to interrogate human-microbe relationships at a critical juncture, asking: what is the impact of the military metaphor on this relationship and how might it be imagined differently?

Fisher states that "Freud's unheimlich is about the strange within familiar" and that being in the presence of the 'weird' often means we are encountering the new and must adjust accordingly. The return of the microbe we cannot control I suggest, invokes this. To reimagine our relationship with the microbial world (the majority of which are either directly beneficial or neutral towards humans) we must confront this. Art has dealt with similar questions of the body through the abject: the "postmodern return to the body' (Ross, 2003: 281) where the "relentless materialism and uncontrollability" of the body is evoked by corporeal entangled fragments (Arya, 2014: 5; Hopkins, 2000: 225). The abject reveals tangibly the 'uncanny' truths about the ecological nature of the 'human' body (such as the revulsion we may feel seeing cultures of bacteria sampled from human bodies). Combining art with multispecies ethnography to investigate human and non-human ecologies, what does it mean to be microbially entangled?

Paper short abstract:

This paper considers the potential applicability of Post-normal Science as a more context-sensitive, transdisciplinary approach to addressing the complex global challenge of anti-microbial resistance and enabling incorporation of anthropological insights into science-policy deliberations.

Paper long abstract:

In this paper, we consider the applicability of a Post-normal Science (PNS) Approach to addressing antimicrobial resistance (AMR) as a major global challenge to human health and wellbeing. The approach used by normal science to manage complex social and biophysical systems as if they were simple scientific exercises has brought us to our present mixture of intellectual triumph and socio-ecological peril. PNS is a new conception of the management of complex science-related issues, focusing on aspects of problem-solving that tend to be neglected in traditional accounts of scientific practice: uncertainty, value loading, and a plurality of legitimate perspectives. It considers these elements as integral to science and science-for-policy. The ideas and concepts belonging to PNS witness the emergence of new problem-solving strategies in which the role of science is appreciated in its full context of the complexity, diversity and uncertainty of natural and social systems and the relevance of human commitments, values and diversity. It is hence able to provide a coherent transdisciplinary framework for extended participation in framing, researching and evaluating real world complex issues by addressing core values such as sustainability, holism, quality, democratization of expertise, methodological pluralism, integration, transparency, responsibility, safety and equity. Standard scientific frameworks are ill-suited to addressing critical globalised issues as significant and complex as AMR with its multidimensional drivers, costs and impacts. We consider whether PNS can provide a more anthropologically receptive, context-sensitive and biologically sensible approach to understanding and addressing the rise and spread of AMR worldwide.