Anti-Microbials In Society (AMIS): a Global Interdisciplinary Research Hub

Our use of antibiotics has escalated. We are often most aware of antibiotic use when we treat infections - for people, and animals. However, their use is more widespread. We use them routinely to reduce risks of infection amongst people with vulnerable immune systems, in farming livestock, to manage infection and to promote growth and even in crop farming. This widespread use is linked to a rise in antibiotic resistance (AMR). The amount of antibiotic chemicals in circulation is held responsible for driving selection pressure amongst bacteria such that some infections become untreatable with previously effective drugs. This can have dramatic consequences for both health and economics. And yet, scientists have emphasised the lack of evidence for using antibiotics in many scenarios. For example, it is estimated that at least 50% of human antibiotic usage has no clinical benefit.

Policy makers are agreed that we must reduce our reliance on these medicines. But how? Efforts to change end user behaviour are often called for but thus far have not had the widespread impacts required to curb the emergence and spread of resistance. In this research, we propose that antibiotics are embedded within our socioeconomic infrastructure in such a deep way that attempts simply to change behaviour of patients, physicians of farmers are peripheral to our underlying dependency on their use. We suggest that by understanding the ways in which antibiotics are intertwined with our lives, institutions and infrastructures today we may identify ways to replace their use while minimising unintended consequences. For example, attempts to reduce use of one antibiotic often increases the use of another. Removing antibiotics all together may require a more systemic intervention such as the promotion of recovery time. In so-doing, however, other consequences could occur for the workforce and for economies tied up with pharmaceutical production and sales. We need to look closely at measures that have already been taken to reduce antibiotic use and understand what their consequences have been, as well as play out potential new interventions in different settings. If we are able to identify effective measures to reduce reliance on antibiotics in different scenarios, this will be more cost effective and timely than one-size-fits-all efforts to change end user behaviour.

The issue of AMR is global, and is expected to have most severe consequences for low and middle income countries (LMICs). The need to reduce use of antibiotics in these settings presents a particular challenge, where markets fill the gaps of fractured health systems. An access-excess balance is described whereby many in need of antimicrobials remain untreated while these medicines are commonly used unnecessarily. This scenario persists despite decades of research and programmes into the rational use of medicines in LMICs. New approaches are needed to uncover the significance of antibiotics in our societies, to understand why the imperative to target their use so difficult to enact.

This project presents a fresh approach beyond the traditionally delineated domains of social, biological or clinical sciences. The project aims to launch the AMIS Hub, an internationally recognised centre of excellence for developing, implementing and disseminating high quality research on antimicrobials in society, and two initial studies in Thailand and Uganda with the following objectives:

1. To understand the roles of antibiotics in every-day life and infrastructure
2. To evaluate the impact on care of imperatives to restrict antibiotics
3. To identify and rehearse counterfactuals to antibiotic use

This project will generate a critical mass of researchers undertaking high quality research into AMR, high quality comparative evidence indicating the nature of our reliance on antibiotics and recommendations for alternatives to antibiotics that will minimise unintended consequences.

Societal benefit
This project intends to deliver societal level benefits of curbing the spread of AMR. The paradox of our reliance on antimicrobials, the common of which use renders them less reliable, is a concern for all those reliant on these medicines. At present, we remain unaware of many of the ways in which antimicrobials are interwoven with our social, physical, biological and economic structures. This prevents us from being able to effectively reduce use of these medicines. It also means interventions to reduce antimicrobial use can have unintended consequences. By examining the interrelationships between antimicrobials and different forms of life and infrastructures, this project will enable more informed measures to be taken to reduce our reliance on these medicines. By evaluating the impacts of different interventions already undertaken, we will also identify consequences of such efforts that may be unanticipated. These can then be taken into account in (re)designing such interventions. By identifying counterfactuals to antimicrobial use, we will be able to explore alternative ways to arrange our infrastructures and cross-species relations.

Policy impact
To enable this societal benefit, the research will need to impact policy. We will ensure that our results enable policy makers to be equipped with possibilities for reducing our reliance on antibiotics whilst understanding the potential consequences of doing so in different scenarios. Our comparison across study sites - different income level countries, over time after different interventions, and in farming and industrial settings - means the findings will be tailored to different scenarios. Furthermore, through the AMIS Hub's network of other research, we will be able to identify commonalities more broadly in possible options to reduce or replace antimicrobial use, as well as in consequences of doing so. These recommendations and considerations can be taken into account in the development of national action plans on AMR.

Target audience
To achieve this policy impact, our target audience will include: (1) political and public health officials in Thailand and Uganda; (2) policy makers and public health practitioners working within and across other LMICs; (3) local officials and members of the public in the study countries and beyond.

Outputs of the research
The two country studies will provide detailed information and examples on: perceptions about antibiotics and AMR; why and how we rely on antibiotics; what are the consequences when antibiotics are not provided; and what alternatives to antibiotics are possible and already in place. The interdisciplinary approach of the project will provide alternative ways of viewing AMR as societal problem, which could contribute to novel configurations of non-academic collaborations and solutions.

Communication strategy
The AMIS Hub will develop a central communications operation which will support each country's engagements with target audiences as well as reaching out to international audiences. In each country, inception meetings with each target group will be held to refine the project plans to meet specific concerns. This will facilitate buy-in and increase the potential for findings to have lasting and meaningful impact. Subsequent meetings will be held in the course of the research and at the end, to discuss progress and findings, and identify possibilities of translating them into meaningful outputs. Specific meeting plans differ between countries due to different political contexts: eg. in Thailand we will visit specific stakeholders and carry out site visits in other regions of this larger country; in Uganda we will utilise established community advisory board methods and will host centralised meetings. Policy briefs will be prepared and translated for each country and a third for cross-study findings, to be distributed at dissemination events in country, in London and at conferences.