Blog – Antimicrobials in Society

Markets and Pharmaceuticals: Hardship, Antibiotics, and Markets for Solutions

Northern Thailand (Chiang Rai), 19 March 2018, 7am: The steep mountain road winds through rice fields, small streams, and coffee and tea plantations. The road surface is still damp from the morning dew, mist is just dispersing at the mountain tops. People come our way walking and on motorcycles to work as farmers and daily labourers; the few who travel with their pickup trucks own the farms, work in town, or are village officials. After a 45-minute ride from the district town, we reach the village.

This route is new, it was only constructed a year ago. In the past, it was not possible to reach the village by car. We heard that food and medical services would only reach the village with great difficulty, and often people would die here as they could not get to a doctor. Since the road was built, access to medical care has improved, but it is still far from easy – the journey to town is tedious, especially if you are ill, or need to travel in the rainy season. Unlike other villages, there is no village health volunteer (a kind of community health worker). Instead villagers only receive half-yearly visits from a neighbouring volunteer. All the medical care in and around the village consists of traditional healers (herbalists and spiritual healers referred to as “ghost doctors”) and two sundry shops that sell things like eggs, soy sauce, soda, detergent, and medicine, including antibiotics. Occasionally, non-governmental organisations (NGOs) come to the village and provide supplies and medicine as well.

Photo credit: Nutcha Charoenboon — Approach road to survey village through mountainous areas and rice, tea, and coffee farms.

Approach road to survey village through mountainous areas and rice, tea, and coffee farms.

We visited this village as part of a rural survey in Thailand and Laos to understand the link between rural health behaviours and antibiotic use, marginalisation, and knowledge diffusion. During our survey interviews, we asked people about these sources of healthcare (Haenssgen et al., 2018b). Part of the information is captured in our questionnaire, quantitatively. But the discussions around these questions were richer (we collected additional qualitative data as well), with people telling us for example that they appreciate the work of the NGOs, but they could not quite remember the NGOs’ names, or even what kind of medicine it was that they brought to the village. For these villagers, the medicine matters insofar as it helps them to continue working. And while some villagers can afford a trip to the nearest town for medical treatment at the hospital or a private clinic, those who do not have a vehicle, or enough money for transit, might choose to buy medicines in the village shops first. As our research intern Penporn (Yok) Warapikuptanun summarised in her conversations, “[the villagers] have to work, to bring food back to their family. That means they cannot get sick. And if they are sick, they better get well quick so they can go back to work because they don’t want to waste time or money to hire a ride [to go see a doctor].” Our survey investigator and research intern Kanokporn (Joobjang) Wibunjak reported similar tendencies: “What’s more important for the villagers isn’t long-term wellness, but not having food to eat and a job to do tomorrow.” People are concerned with their own and their families’ subsistence and survival – antibiotic resistance or side-effects of medicines take a subordinate role in this environment.

We carried out educational activities in this setting, both for us to learn about villagers’ lives and their conceptions of medicine, but also to share some of the ideas about antibiotic resistance with the villagers (our purpose was not to change their behaviour actively towards any particular ideal). We were conscious that villagers do not necessarily think in terms of antibiotics, bacteria, or even infectious diseases. We therefore drew on insights from our previous qualitative research and benefitted from the ideas and viewpoints of three research local interns to develop activities that built on language and conceptions of rural Thai dwellers (Haenssgen et al., 2018a; Khine Zaw et al., 2018). The half-day activity was attended by 30 out of the 400 villagers.

Did it work? Take the example of a teacher who participated in the village and who also lived in the village and maintained strong social ties in the community. Although he discussed the activity on social media with his friends outside of the village, he did not talk to anyone else in the village about it.

“Language and concepts did not seem to be the problem, but rather it seems that ideas about antibiotic resistance, the side-effects of medicine, and consultation from medical doctors did not resonate with his experiences of hardship and poverty in the village.”

Villagers draw maps of village and health providers during public engagement activity.

Globally, policies and interventions to change people’s antibiotic use remain firmly locked into education and awareness raising campaigns (Haenssgen et al., 2018b). Education and awareness campaigns operate on the logic that the population has a knowledge deficit, and that the rectification of this will improve behaviour (which may indeed be the case for a subset of the population). Considered from a conventional (neoclassical economics) market perspective, this approach would make sense insofar as new information would influence people’s preferences and therefore the demand for goods, like antibiotics. Telling people to not take antibiotics would help to deflate demand and might make them use herbal medicine instead.

Well-meaning educational campaigns, however, can miss their target if they assume that people take antibiotics because they believe them to be a magic pill that will cure all their ailments. Rather, people here tended to take any available medicine to help them cope with precarious situations. For many, it didn’t matter – nor did they know – if what they took was an antibiotic or not.

One of the main limitations of the conventional market logic that corresponds to this reductionist perspective is the focus on a single product or family of products. Although it is abundantly common, it is not necessarily intrinsic to definitions of “the market.” An alternative conception can be found in the field of strategic management (Abell, 1980), which suggests that a market does not just comprise products, but more general functions that a consumer aims to fulfil, and different types of solutions or technologies can fulfil these functions. Accordingly, a product (e.g. antibiotics) may compete with an altogether different industry (e.g. crop insurance) in fulfilling a consumer function (e.g. economic security). (Consider for instance Skype as it competes with airline companies for communication in transnational business and long-distance relationships.)

Antibiotic prescription and use, even if they are deemed “inappropriate” by outsiders, are part of a network of solutions to meet health-related and broader functions among the general population (Haenssgen et al., 2018b). This network constitutes potential competition for new interventions to reduce antibiotic use, and education and awareness-raising campaigns are by no means the intuitive or only response from a strategic management perspective. Anthropological and sociological research can help uncover what functions people fulfil by using antibiotics and what therefore constitutes the relevant “market,” but it also raises critical questions as to who articulates the problems of a population and who defines the corresponding solutions and interventions.

References

– Abell, D. F. (1980). Defining the business: the starting point of strategic planning. Englewood Cliffs, NJ: Prentice-Hall.
– Haenssgen, M. J., Charoenboon, N., Althaus, T., Greer, R. C., Intralawan, D., & Lubell, Y. (2018a). The social role of C-reactive protein point-of-care testing to guide antibiotic prescription in Northern Thailand. Social Science & Medicine, 202, 1-12. doi: 10.1016/j.socscimed.2018.02.018
– Haenssgen, M. J., Charoenboon, N., Zanello, G., Mayxay, M., Reed-Tsochas, F., Jones, C. O. H., et al. (2018b). Antibiotics and activity spaces: protocol of an exploratory study of behaviour, marginalisation, and knowledge diffusion. BMJ Global Health, 3(e000621). doi: 10.1136/bmjgh-2017-000621
– Khine Zaw, Y., Charoenboon, N., Haenssgen, M. J., & Lubell, Y. (2018). A comparison of patients’ local conceptions of illness and medicines in the context of C-reactive protein biomarker testing in Chiang Rai and Yangon [epub ahead of print]. American Journal of Tropical Medicine and Hygiene. doi: 10.4269/ajtmh.17-0906

Notes

This blog entry derives from a presentation at the Oxford Tropical Network 2018 Conference, it is a description of a forthcoming paper on the use of the strategic market definition in AMR, and it has benefitted from comments from Giacomo Zanello. We explore the implications of our educational activities in Thailand in another forthcoming paper on “Translating AMR: A Case Study of Three Thai Villages.” The current portfolio of publications related to this conceptual work includes:

– Haenssgen, M. J., Charoenboon, N., Zanello, G., Mayxay, M., Reed-Tsochas, F., Jones, C. O. H., et al. (2018). Antibiotics and activity spaces: protocol of an exploratory study of behaviour, marginalisation, and knowledge diffusion. BMJ Global Health, 3(e000621). doi: 10.1136/bmjgh-2017-000621
– Khine Zaw, Y., Charoenboon, N., Haenssgen, M. J., & Lubell, Y. (2018). A comparison of patients’ local conceptions of illness and medicines in the context of C-reactive protein biomarker testing in Chiang Rai and Yangon [epub ahead of print]. American Journal of Tropical Medicine and Hygiene. doi: 10.4269/ajtmh.17-0906
– Haenssgen, M. J., Charoenboon, N., Althaus, T., Greer, R. C., Intralawan, D., & Lubell, Y. (2018). The social role of C-reactive protein point-of-care testing to guide antibiotic prescription in northern Thailand. Social Science & Medicine, 202, 1-12. doi: 10.1016/j.socscimed.2018.02.018
– Haenssgen, M. J., Charoenboon, N., & Khine Zaw, Y. (2018). It is time to give social research a voice to tackle AMR. Journal of Antimicrobial Chemotherapy, 73(4), 1112-1113. doi: 10.1093/jac/dkx533
– Haenssgen, M. J., & Ariana, P. (2017). The social implications of technology diffusion: uncovering the unintended consequences of people’s health-related mobile phone use in rural India and China. World Development, 94, 286-304. doi: 10.1016/j.worlddev.2017.01.014

About the Authors

Dr Marco J Haenssgen is a social scientist with a background in management and international development and experience in aid evaluation, intergovernmental policy making, and management consulting. His research emphasises marginalization and health behaviour in the context of health policy implementation, technology diffusion, and antimicrobial resistance (AMR). His AMR-related research in Southeast Asia focuses on population behaviour, how people understand antibiotics and illness, their constraints in accessing healthcare, and the intended and unintended consequences of AMR interventions. His research also involves antibiotic-related public engagement activities with villagers in northern Thailand and southern Lao PDR. He is the Principal Investigator of “Antibiotics and Activity Spaces,” a Theme-4 project funded by the UK Research Council’s AMR Initiative.

Nutcha (Ern) Charoenboon is based at the Mahidol-Oxford Tropical Medicine Research Unit in Bangkok. She is a biologist with extensive volunteering and public engagement experience, and currently works as research officer on the project “Antibiotics and Activity Spaces,” where she manages qualitative and quantitative data collection and AMR-based educational activities among teams of 20 field investigators and research interns. Her research interests relate to the drivers of people’s medicine use and treatment choices, and the unintended consequences of public engagement.

The Antibiotics and Activity Spaces project is a study of antibiotic-related health behaviour in rural Thailand and Lao PDR, funded by the Antimicrobial Resistance Cross Council Initiative supported by the seven research councils in partnership with the Department of Health and Department for Environment Food & Rural Affairs (grant ref. ES/P00511X/1, administered by the UK Economic and Social Research Council). The Economic and Social Research Council (ESRC) is the UK’s largest funder of research on the social and economic questions facing us today. It supports the development and training of the UK’s future social scientists and also funds major studies that provide the infrastructure for research. ESRC-funded research informs policymakers and practitioners and helps make businesses, voluntary bodies and other organisations more effective. The ESRC also works collaboratively with six other UK research councils and Innovate UK to fund cross-disciplinary research and innovation addressing major societal challenges. The ESRC is an independent organisation, established by Royal Charter in 1965, and funded mainly by the Government.

The CABDyN Complexity Centre at the Saïd Business School engages in research on complex systems and networks, with a particular focus on the social, economic, financial, communication and infrastructural networks that underpin most of modern life. The acronym CABDyN stands for Complex Agent-Based Dynamics Networks, and reflects some of the techniques such as complex network analysis and agent-based modelling that the Centre’s researchers typically use to understand these systems. The activities at the Saïd Business School form part of a larger research network that applies shared methods and techniques to a broad range of problems and domains. CABDyN was established in July 2003 as a research cluster spanning the University with the seed funding under the EPSRC Novel Computation Initiative, and currently brings together a truly multi-disciplinary group of researchers across Oxford, ranging from the physical, biological and computational sciences to the social, economic and political sciences.

The Centre for Tropical Medicine and Global Health (CTMGH) is a collection of research groups within the Nuffield Department of Medicine, University of Oxford, who are permanently based in Africa, Asia and Oxford. Its research ranges from clinical studies to behavioural sciences, with capacity building integral to all of its activities. The majority of the Centre’s research is conducted at three Wellcome Trust Major Overseas Programmes in Kenya, Thailand and Vietnam, as well as at the Oxford Centre for Global Health Research. The Centre for Tropical Medicine and Global Health also brings together a number of sister groups in Cambodia, the Democratic Republic of the Congo, Indonesia, Laos, Myanmar, Nepal, and Uganda, and collaborators around the world. Tackling infectious diseases, which kill many millions of people every year, is one of the greatest challenges of the 21st century. The CTMGH is researching solutions to the increasingly urgent problems these diseases cause.

The Mahidol Oxford Tropical Medicine Research Unit (MORU) develops effective and practical means of diagnosing and treating malaria and other neglected diseases such as melioidosis, typhus, TB and leptospirosis. MORU was established in 1979 as a research collaboration between Mahidol University (Thailand), Oxford University (UK) and the UK’s Wellcome Trust. MORU’s main office and laboratories are located within the Faculty of Tropical Medicine at Mahidol University in Bangkok, Thailand, with MORU study sites and collaborations across Thailand, Asia and Africa.

Fresh Perspectives

Antimicrobials are central to many contemporary forms of care and production for humans, animals, plants and even objects – clothing, for example, uses antimicrobials in the production process. The sheer scale of our current dependence on antimicrobials means that in order to have any chance of addressing antimicrobial resistance (AMR) we are greatly in need of fresh framings, approaches and solutions.

Currently, much of our understanding of the social side of AMR has come from KAP surveys and cultural belief models. Social sciences, however, have much more to offer. There is great potential to learn from the considerable research from across the social sciences, to provide broader and richer approaches that can contribute to effective strategies to address AMR.

The AMIS Hub draws together these fresh approaches in one place. Much of the work we showcase on our website highlights the structural and historical factors that affect antibiotic use, illustrating the complex stories behind our relations with microbes and antimicrobial medicines across the world today. These fresh approaches can help us to study and anticipate consequences – intended or not – of both AMR and AMR control strategies globally.

Social science studies of antimicrobials bring to the fore the rich social-material worlds that microbes and antimicrobials are situated in, and in doing so offer policy-makers, scientists, and funders new ways to conceptualise and act upon AMR. For example, anthropologists propose that antibiotics are so deeply embedded in the way our societies, politics, and economies work, that it makes sense to think about them as a kind of infrastructure that enables life as we know it (Chandler, Hutchinson and Hutchison 2016). If antimicrobials are infrastructure, it is important to understand the extent and nature of the way we have become intertwined with these medicines in order to anticipate the consequences of resistance and the best ways to control it. While a ‘rational use’ framework has informed many AMR policy undertakings over the past few decades (Podolsky 2014), and anthropologists have provided evidence of consumers’ own rationalities for use of medicines (for a review, see Chandler and Hutchison 2016), it is valuable to go beyond the rational-irrational dichotomy if we are to understand and address our collective dependencies on antibiotics and the ways we have come to relate to and control microbes today.

The AMIS HUB is a vehicle for thinking about these new perspectives. Please explore and always feel free to reach out to us with your questions!

Can Bangladesh’s aquaculture be sustainable without antibiotic use, and what is required to achieve this?

We – the field team – arrive at the village of Akra shortly after 9am. The village is divided in two by a road-cum-dam. On one side sit shrimp ponds fed by high saline river tidal flows; on the other sit ponds fed by saline water combined with fresh groundwater [1]. The majority of farmers here have finished their shrimp harvest and are moving to rice cultivation for the winter season. The rice being cultivated in fields on the high saline side does not grow as well and looks quite dry. We are led to a gazebo in the village with farmers and curious villagers gathered around. The NGO representative introduces our project whilst the data enumerators prepare the surveys. A research assistant translates as the NGO representative talks to those farmers taking part in our survey. The villagers fire questions at him: “how do we stop our shrimp dying?” He fires questions back: “how do you think? What is required for successful production?” “Oxygen” some reply, “sufficient water” say others. They seem unconvinced by the representative’s suggestions for improving their technique. They know how to farm —the problem is their techniques are becoming less effective.

“Given these circumstances, will antibiotic application come to be considered the quick and easy solution for managing disease? Our research suggests that in situations of increasing economic and environmental precarity, resistance pathways are trodden through shifting and interconnecting human, non-human animal, environmental and microbial terrains. Successful AMR interventions will need to accommodate social, economic and material realities, along with the diverse geographies of human, landscape and microbe interrelations.”

Rather than asking how antibiotics enable livelihoods in situations of increasing precarity, our research asks whether it is possible to enable livelihoods without antibiotics in precarious situations, and what is required to achieve this?

As the role of aquatic environments in the emergence, persistence and distribution of AMR is increasingly understood (Taylor et al 2011), we turn our attention to crustacean aquaculture-for-export practices in Bangladesh. Aquaculture is the fastest growing food production system globally. In order to meet the demands of a growing global population, production systems have been adapted and intensified, resulting in routine antibiotic use and the emergence of lethal pathogens—including some that are highly lethal for shrimp.

Bangladesh’s dominant farming systems are different—a result of diverse historical contingencies. The southwest coastal region is a mosaic of some 200,000 extensive aquaculture ponds characterised by low stocking densities, feed cultured in the ponds, few inputs and little in the way of medicines, including antibiotics. The majority of farmers practice polyculture (stocking of multiple fish and crustacean species) methods and often combine their farming with rice paddy production. Extensive systems are lauded by sustainable development lobbyists for their organic, environmentally sustainable practices, but nevertheless, Bangladesh’s shrimp and prawn farmers face a high disease burden that threatens their crops and their livelihoods.

A strong network of external financial support and local NGO activity works to improve aquaculture through the delivery of technological innovations. But the language of improved farming changes depending on who you talk to. Some organisations promote greater intensification and domestication of the farming system, promoting artificial environments and stringent operating procedures to keep pathogens at the pond barrier. They provide funds to expand hatchery technology to produce specific pathogen free (SPF) shrimp seed—a captive breeding and domestication programme that involves the genetic improvement of wild-caught healthy shrimp mothers, whose spawn are nursed and sold to farmers. Other international NGOs encourage the small-holding model, offering finances and technical expertise to support organic adaptations and pathogen management strategies to improve pond microbiomes. Some interventions combine aspects of both methods. No external organisation promotes antibiotics as a strategy for managing disease.

Certain farming communities embrace interventions more enthusiastically than others, although those praising the benefits of SPF shrimp seed and the application of probiotics to improve pond and animal health tend to have better management strategies – and more economic power. Other farming communities, for example in those in the high saline district of Satkira, choose to replicate natural habitats as far as possible, using homemade probiotics of rice husk, molasses and yeast, and preferring to stock with wild shrimp fry as they say that SPF spawned shrimp are unable to adapt to their local pond conditions. Once again, no farming community favours the use of antibiotics.

Yet many suffer the burden of disease. Why are Bangladeshi shrimp and prawn farmers facing this situation?

A combination of social and material determinants potentially produce environments that allow disease to express within the ponds. The high volume of ponds discharging untreated cultured water into the environment facilitates pathogen transmission between ponds. Climate shocks (droughts, floods and cyclones) and industrial damning upstream impact water flow and quality. For a variety of reasons, the majority of farmers surveyed struggled to maintain the required water depth. Pathogens and antibiotic resistance may enter ponds with hatchery reared shrimp and prawn seed, as hatcheries are sites where antibiotics are more likely to be routinely used, and financial support for routine testing of seed for pathogens remains lacking. Industrial, clinical and agricultural waste contain heavy metals, detergents and pollutants that can select for AMR, contributing to the disease ecologies of hydrological systems. Shrimp and prawn—some that have begun life as artificially produced seed—are now made to live and relate to a bewildering network of agents: hostile pond environments, polluted water, new probiotics, new medicines, land management systems, non-cohering technical interventions, and food safety regulations.

Intervention instructors insist upon rigorous implementation of operating procedures: “You need to do everything right if you are to have successful production…” one fisheries expert and project manager tells me, “…not just cherry pick the parts of the procedures that you trust most, or that you can afford”. However, our research suggests that interventions are not necessarily compatible with small-scale farming methods, increasingly hostile aquatic environments, and the social and material abilities of farmers to respond to disease. What began in the 1970s as farming adaptations to improve income and lift farmers out of poverty has now become a precarious livelihood. If production is successful, a homestead can make good money. But the emergence of new diseases and an increasingly unpredictable and hostile environment constrains innovation, forcing farmers to tweak production strategies and culture methods with the knowledge and the material resources available to them.

Given these circumstances, will antibiotic application come to be considered the quick and easy solution for managing disease? Our research suggests that in situations of increasing economic and environmental precarity, resistance pathways are trodden through shifting and interconnecting human, non-human animal, environmental and microbial terrains. Successful AMR interventions will need to accommodate social, economic and material realities, along with the diverse geographies of human, landscape and microbe interrelations.

[1] (although the Bangladeshi government limits how much fresh water farmers can use for aquaculture).

‘Notes from the Field’: Wakiso District, Kampala, Uganda

How are antibiotics a kind of infrastructure that enable livelihoods in landscapes of scarcity and uncertainty?

We’ve wound our way through Kampala towards the southern suburb of Wakiso to visit a chicken farm run by Sarah, a former primary school teacher, in the back of her house. Keeping chickens in your backyard wouldn’t be so remarkable in an East African city, except this is neither a small-holder, nor a large commercial, operation. Rather, this is something in between. Sarah keeps over 1000 chickens, almost an even mix of layers and broilers, in four large double-story pens pieced together with rough boards, all just located in her back garden. Sarah has been doing this work for over 20 years. At first it was a way to supplement her income as a teacher, but now it’s a full-time job that supports her extended family, puts four students through university, and has even allowed her to afford a once unimaginable trip to Mecca. She employs two young women to assist her in keeping the pens tidy and in collecting eggs, but the care of the chickens is all done by her.

Sarah is carefully attuned to her chickens’ health, monitoring their coughs, sneezes, excrement, even any drooping feathers. As we walk amidst the birds, she points out one chicken to us in a pen of hundreds that she is currently treating for an unnamed sickness, and tells us about various home remedies and her use of antibiotics to tend to it and other sick birds. When we inquire where she’s learned all she knows about poultry keeping, she is clear that it is a matter of experience, of really knowing the birds, and of carefully paying attention to their needs. She laments, for example, that she doesn’t have space for her own garden, and has to collect nearly-rotten fruit from the markets to supplement the home-made feed she makes and sells. Fresh herbs from the garden would be best, she tells us, but she is confident in the feed she now mixes herself. It is a special recipe put together after years of observing what hens need most to thrive, invented after years of paying for over-priced commercial feeds with unknown ingredients. She uses antibiotics on individual sick chickens, she tells us, rather than dosing them pre-emptively. Since veterinary outreach services are so limited, she explains, she has had to learn everything via experience and through costly piece-meal agricultural courses over the years, including selective antibiotic dosing, vaccinating chicks, beak trimming, and which antibiotics to include in their feed for optimal growth and health.

Photo by author — Wakiso District, Uganda

This size of a poultry farm is a somewhat new addition to the farming landscape in Wakiso. As the suburbs shift in character, related to new urbanizing patterns, the rising cost of housing in the centre, young urban dwellers’ desire for agricultural investments near the city, and the emergence of new suburban hubs, farming trends are changing along with it, allowing new medium-sized operations to flourish. All of this is linked, of course, to the availability of antibiotics too, which potentially lessens the risk of making the investment into larger flocks.

Our current research project in Wakiso takes all of this as its focus. We are interested in the dynamics of suburban farming and antibiotic use, carefully considering how antibiotics are part of the infrastructure (Chandler 2018) that undergirds complex urban livelihoods in landscapes of scarcity and uncertainty. How are antibiotics used to make everyday life possible? How is experience made into knowledge? How do antibiotics figure as a kind of care – for both sick animals and the families that are supported through their keeping? What new antibiotic markets are emerging to support these arrangements?

Works Cited:

Chandler, Clare. Forthcoming 2018. ‘Antimicrobial Infrastructures: Addressing Resistance as a Problem of Connectedness’ . Antibiosis.

Welcome to the AMIS Hub!

‘How do we get patients to stop demanding antibiotics?’ is a question I have frequently been asked. Not only by journalists trying to get a handle on this latest hot topic, but also by other scientists and policy makers. Taking this question seriously has started several lines of action.

First, it has prompted primary research into the realities of antimicrobial usage, which has quickly shifted from the concept of patient demand to societal requirement. Patients infrequently directly demand antibiotics. In what ways have societies developed materially, economically, even morally, in conjunction with antimicrobials, such that these medicines are needed for the fabric of life to continue? We explore these questions in our empirical research projects AMIS Thailand and AMIS Uganda.

Second, this question prompts reflective practice into the reasons we formulate the problem of AMR around patient misuse of medicines. This follows in the path of other public health programmes that have isolated patient ‘lifestyle factors’ as solutions despite knowledge of societal drivers of diseases such as obesity. And it follows a long-standing discourse of ‘rational drug use’ whereby a ‘right case, right drug, right duration’ ideology can be applied. Science, however, continues to surprise us and AMR is surrounded by scientific uncertainties, including the significance for resistance of short doses of antibiotics taken before a patient feels better. How can truly interdisciplinary research be undertaken to understand the best courses of action, with least negative reaction, to address AMR?

Third, these questions pose another: don’t we already have some of these answers? Reviewing social literature revealed that indeed there is substantial social theory that can be applied to thinking about AMR. Such theory can catalyse innovative thinking and help move beyond existing models that constrain our understanding of AMR and potential solutions. This is being demonstrated by the range of strong social research currently being undertaken across the globe. However, much of the relevant literature is in books or not easily found online, and can be intimidating for those without a first degree in the social sciences, it seemed important to make this literature more visible and legible to a broad range of researchers and decision makers. It also seemed useful to profile high quality ongoing social research on AMR in order to draw connections and anticipate outputs. And so, the AMIS Hub online resource was born. Through the website, we connect readers with ‘Essential Reading’ , which we summarise to illustrate relevance to AMR; we help to frame these in terms of bodies of work through our ‘Themes’ ; and we provide connections with the ‘People ’ doing the latest social science in AMR in an exciting range of projects around the world.

Today as our new AMIS Hub website goes live, I am thrilled that this idea has come into being. I hope we generate new connections both conceptually and collegiately, and push beyond traditional boundaries and framings to address this important issue for the health of humans, animals, and our globe.

As this is our first commentary, and there has been a huge effort getting to today, I would like to note my gratitude to the whole AMIS programme team – in Thailand, Uganda and London , especially Bianca D’Souza, Laurie Denyer-Willis and Pat Ng who have done all the hard work in getting this live, and to our photographers in Thailand and Uganda whose photos make the site so captivating. Thank you!