Changing Food Systems in Kenya and Malawi and the Challenge of Tackling Antimicrobial Resistance

This research partnership involves a two-year programme of work focused on the ways in which rapidly changing cultures of poultry meat consumption and agricultural systems in particular Low and Middle Income Countries (LMICs) shape antibiotic use/misuse in farming, with implications for tackling the global antimicrobial resistance (AMR) health challenge. AMR, or in lay terms drug-resistant infections, is one of the top five priorities for the World Health Organization (WHO). The 2016 O'Neill report into 'Tackling Drug-Resistant Infections Globally' warns that if the challenge is left unaddressed, deaths resulting from AMR on a global scale are predicted within the next three decades to reach some 10 million per year. AMR in agriculture and food systems is a critical area of concern, with increasing cases reported of strains of bacteria such as E.Coli, Campylobacter and Salmonella developing resistance to particular groups of antibiotics. While antibiotics are a necessary tool to maintain health and welfare on the farm, the problem is their inappropriate and disproportionate use in animals, thereby reducing availability for humans and also catalysing resistance. The first aim of the research partnership is to evaluate the relationships between changing urban diets incorporating increased meat consumption, transforming food systems and the use/misuse of antibiotics in agriculture. It will do so through a focus on the poultry sectors of Kenya and Malawi, in particular the urban contexts of Nairobi and Lilongwe, given the rapid rise of poultry production and consumption in both places and the increased and weakly regulated use of antibiotics in production. Moreover, Kenya and Malawi are a Lower Middle Income Country and a Least Developed Country, respectively, on a continent predicted to see the highest mortality rate from AMR by 2050. The second aim is to generate culturally and geographically sensitive approaches to antibiotic reduction and stewardship initiatives in these contexts, in ways that improve implementation of their governments' AMR National Action Plans. The premise of the research is that policies and targets for the reduction of antibiotic misuse in agriculture, whilst shaped by the WHO and a 'One Health' agenda, are most likely to be effective if their implementation is responsive to the specific pressures, constraints and opportunities experienced by farmers in the context of the particular food systems in which they are embedded, and to the cultural values shaping everyday farming practice.

The partnership brings together an interdisciplinary team and wider network of researchers and policy-makers across Kenya, Malawi and the UK. The core team represent the African Population and Health Research Center in Nairobi, the University of Malawi, Newcastle University, Southampton University and UCL. Collaboration in the partnership involves dialogue between the disciplines of Geography, History, Epidemiology, Medicine, Anthropology, Microbiology and Art to understand how cultural values and practices are integral to antibiotic use/misuse in the particular food systems and poultry sectors of Kenya and Malawi. The partnership also involves influential AMR policy institutions on its advisory board, including the UK's Food Standards Agency, the UN's Codex Alimentarius, Malawi's Ministry of Health and the International Livestock Research Institute in Kenya as Project Partners. The model for the partnership involves a programme of interwoven scoping research, involving secondary and primary data collection in Kenya and Malawi, and three intensive workshops in London, Nairobi and Lilongwe. Research will develop understanding of the embeddedness of antibiotic use and AMR awareness in everyday cultures and practices of subsistence and commercial farming. From this research, recommendations will be made to Kenyan and Malawian AMR policy-makers regarding culturally-sensitive and effective approaches to antibiotic stewardship.

The impact objectives of our research partnership will ensure that improvements are made to the implementation of antibiotic reduction and stewardship policies in the poultry sectors of Kenya and Malawi. This is important for animal and, by extension, human health in these Low and Middle Income Countries, given the increasing threat of antimicrobial resistance (AMR) (drug-resistant infections). The objectives of our partnership are aligned closely with those of the recently-formed AMR National Action Plans of Kenya and Malawi, framed by the WHO's Global Action Plan for AMR initiated in 2015. The thematic priorities of both National Action Plans involve making improvements to: education and awareness of AMR; AMR surveillance and research; infection prevention; optimal and more prudent use of antimicrobials; and investment in new antimicrobial agents. These priorities target agriculture as well as human healthcare settings. Most directly, the research will develop intervention aimed at improvement in the prudent use of antimicrobials in farming (stewardship initiatives), with AMR awareness-raising and education being a part of this. The research will shed light on current practices of antibiotic use/misuse in the poultry farming systems of Nairobi in Kenya and Lilongwe in Malawi, from which approaches will be developed and recommended regarding culturally-sensitive ways of encouraging reduction in the use of antibiotics and improved stewardship. Outcomes will be both recommendations to AMR policy groups concerning approaches to education and improved stewardship and prototype educational and training materials (e.g. leaflets and posters) incorporating artwork, which can be can used with large and small-scale farmers.

There are two main groups of user communities to benefit from the research: policy-makers and poultry farmers, with potential in the future also to reach consumers with AMR awareness-raising materials. First, policy-makers are the government departments and committees responsible for refining and executing the Kenyan and Malawian AMR National Action Plans. In Kenya, at the national level it is the Ministry of Health in the lead role and other ministries including the Ministry of Agriculture. County governments are involved in implementation and monitoring, coordinated by a multi-sectoral AMR Secretariat and national and county level Antimicrobial Stewardship Interagency Committees and Technical Working Groups. In Malawi, equivalents are the AMR National Coordinating Centre in the Ministry of Health, supported by the Ministry of Finance, Ministry of Agriculture and Food Security and the Ministry of Natural Resources, Energy and Mining. These policy-making beneficiaries will gain a deeper understanding of antibiotic use/misuse in terms of the practices and drivers in the food system, which will then provide steers for effective approaches to AMR education and antibiotic stewardship. Kenyan and Malawian user groups also stand to benefit from knowledge exchange. AMR policy-makers at the international level are also amongst the beneficiaries via the UN's global food standards committee, Codex Alimentarius, which has as one of its objectives identifying impactful interventions at different stages of the food supply network. The African Regional Committee of Codex will also therefore be a recipient of the research recommendations. The second group of users are poultry farmers, both commercial farms and smallholders engaged in subsistence farming. The partnership will pilot educational materials that can be used with farmers for AMR awareness-raising and prudent use of antibiotics. Commercial farms stand to benefit by being more informed and better positioned to comply with tightening regulation and requirements from corporate buyers, and as also with smallholders, to manage disease and AMR risk more effectively.