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Anti-Microbials in Society (AMIS) Hub

Fresh approaches to the study of antimicrobials in society.

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About us

The AMIS programme ran from 2017 to 2021, with the aim to promote and produced high-quality research on antimicrobials in society by building on social and interdisciplinary research for innovative and insightful solutions to antimicrobial resistance.

Visit our AMIS Hub website - www.antimicrobialsinsociety.org – an online resource connecting you with relevant research, people and projects on AMR from a societal perspective.

Who we are

The AMIS team was comprised of a team of researchers in the UK, Thailand, and Uganda undertaking research into the nature of our reliance on antimicrobials in animal, human and plant life.

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About
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AMIS Uganda

Antimicrobial resistance (AMR) is a potentially catastrophic global problem. Our use of antimicrobial drugs, including antibiotics, has escalated. These medicines are now a routine part of everyday life. For example, we use antibiotics not only to cure infections but in anticipation of infection for people, animals, and crops. Through this project we proposed that the ways antibiotics are used is deeply embedded in the way our societies and economies work. It is important to understand the extent and nature of the way we have become intertwined with these medicines in order to understand the consequences of resistance and the best ways to reduce the threat of resistance.

Policy makers have agreed that to address AMR we must reduce our reliance on antibiotics. But how? The AMIS programme explored fresh approaches to the study of antimicrobials in society. Drawing on conceptual and methodological tools from anthropology, the AMIS research projects demonstrated the multiple roles that antimicrobials take in society today, and how they enable everyday life. 

The AMIS programme aimed to stimulate engagement with social research that presents different ways of conceiving, responding to, and framing global health issues, including AMR.

 

Research themes
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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 2008Kamat 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.

 

Who we are
Profiles
London-based
AMIS Hub Principal Investigator

Professor in Medical Anthropology, London School of Hygiene and Tropical Medicine (LSHTM). Clare’s research focus has been on the use of antimicrobial medicines and diagnostics in global health. She directs the LSHTM Antimicrobial Resistance Centre and leads the Anthropology of AMR research group.

Coll Hutchison

Coll Hutchison

Research Fellow
AMIS Hub co-Investigator

Coll is an anthropologist of science from LSHTM’s Department of Global Health and Development. His current research explores the roles of moralising metaphors, modern myths and scientific knowledge in the production of different antibiotics and AMR politics.

Laurie Denyer Willis

Laurie Denyer Willis

medical anthropologist

Laurie is a medical anthropologist concerned with the urban and political ecologies of health and disease in post-colonial landscapes. Her research explores animal-human relations, religion, and shifting meanings of care.

Thailand-Based

Our research team in Thailand brings together leading medical anthropologists from Mahidol University and the Ministry of Public Health. Research will be based in Nakhon Pathom, near Bangkok, and will include the mapping of antibiotic use, and the networks that antibiotics travel within, including in farms, factories, laboratories, and during medical practice. The research will also follow antibiotics, microbes, and discourses to national and international arenas.

Komatra Chuengsatiansup Profile Pic

Komatra Chuengsatiansup

Ministry of Public Health Thailand
AMIS Hub co-Investigator

Komatra has researched community health and social policy including community drug use, village health volunteers, and primary care in Thailand. As a medical anthropologist working in the Ministry of Public Health, his works are instrumental in integrating an anthropological perspective in health policy development and implementation.

Luechai Sringernyuang

Luechai Sringernyuang

Mahidol University, Thailand
AMIS Hub co-Investigator

Luechai Sringernyuang is an Associate Professor in medical anthropologist, Director of Health Social Science International Programme and Dean of the Faculty of Social Science and Humanities at Mahidol University, Thailand. He has extensive research experience in pharmaceutical use in Thailand, especially self-medication with modern pharmaceuticals in rural communities.

Phakha Whanpuch Profile

Phakha Whanpuch

Mahidol University

Phakha's research interest in AMR is to better understand the role of antimicrobials in daily life in Thai society, including with health care providers, farmers, day wage urban workers, scientists and policy-makers.

Silpakorn University

Panoopat is a medical sociologist and pharmacist who works as a faculty member at Department of Community Pharmacy, Silpakorn University. Panoopat has research experience in ethnographic studies on the phenomenon of medicine use by kathoeis (transgender women) to modify their bodies.

Ministry of Public Health Thailand

Thitima is an anthropologist at the Society and Health Institute. Thitima conducts ethnographic research focusing on antimicrobial use in tangerine plantations.

Ministry of Public Health Thailand

Uravadee is researcher at the Society and Health Institute. Her background is in Medicine and Medical Sociology. Uravadee wrote her master thesis on the medical socialization of Thai physicians. Currently, Uravadee is conducting research related to social factors affecting how Thai doctors prescribe antibiotics.

Ministry of Public Health Thailand

Wirun's research focuses on the use of the “bio-social interaction framework” - linking in-depth biological studies and social analysis - to understand the global and local problems of antimicrobial resistance. 

Sittichoke has a Master degree of Anthropology and wrote his thesis about patients with mental illness. Currently, Sittichoke works under the Culture and Health risk project.

Uganda-based

Our research team in Uganda is based at the Infectious Disease Research Collaboration (IDRC). The research will involve three study sites, seeking to understand how antimicrobials shape and enable ways of life within health care facilities across Tororo, among urban workers in Kampala, and in different scales of chicken and pig farms in peri-urban Wakiso and rural Tororo.

Susan Nayiga

Susan Nayiga

Infectious Disease Research Collaboration
AMIS co-Investigator

Susan is a social scientist with the IDRC in Uganda. Her current research is on understanding the consequences of tackling antimicrobial resistance in Uganda. She is interested in understanding how the imperative to restrict antibiotics impacts care.

AMIS Hub co-Investigator

Professor of Malaria & Global Health, LSHTM and IDRC, Kampala, Uganda. Sarah is a clinical epidemiologist based in Uganda where she has conducted research since 1999. Her research is focused on methods to improve quality of care and fever case management, and novel approaches to prevent and control malaria.

Infectious Diseases Research Collaboration

Christine is a medical sociologist and pharmacist at the IDRC in Uganda. She has substantial experience in qualitative research informed by medical anthropology, with a special interest in researching health care delivery in low resource settings.

Mentors
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AMIS Mentors

The AMIS programme is guided by a group of researchers, which span the humanities, biological, clinical, and social sciences, to give advice and support.

History:

Sociology:

Anthropology:

Geography:

Clinical:

Microbiological:

Pharmacological:

Veterinary:

Policy:

Economics:

  • Professor Richard Smith, Exeter
  • Professor Kara Hanson, LSHTM

 

Thailand
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AMIS Thailand
AMIS Thailand

AMIS Thailand teams have jointly established an archive of the AMIS project’s materials in the Society and Health Institute’s (SHI) research data center, supported by the AMIS project. This data center is a part of SHI’s plan to make “AMIS” a multidisciplinary research space, with SHI serving as its national and regional hub. Its aim being to continue the legacy of AMIS and further support those engaged with policy, practice and research to focus antimicrobial resistance and antibiotic use “in society”. The AMIS archive includes five categories of material from the project: research management, research processes, research data, outputs, and key references. This archive will be available and accessible online at the National Archive of Public Health, Thailand.

Our research team in Thailand brought together leading medical anthropologists from Mahidol University and the Ministry of Public Health. Research is based in Nakhon Pathom, near Bangkok, and includes the mapping of antibiotic use, and the networks that antibiotics travel within, including in farms, factories, laboratories, and during medical practice. The research follows antibiotics, microbes, and discourses to national arenas.

The AMIS Thailand: Ministry of Public Health project team consists of:

The AMIS Thailand: Mahidol University project team consists of:

Our research teams in Thailand have compiled two short films as part of the dissemination of key findings from their research. To view the films please visit the AMIS Youtube channel. 

Antimicrobials in Society (AMIS): When Anthropologists are Challenged by the 21st-Century World

Antimicrobial Resistance, Urban Life in Thailand and Anthropological Research 

Uganda
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AMIS Uganda
AMIS Uganda

The research in Uganda was aimed to better understand the roles of antimicrobials in society and everyday life. We aimed to identify how antimicrobials shape and enable ways of life within health care facilities, among urban workers, and in animal farming. By researching how people actually use antimicrobials, including antibiotics, and the wide-reaching reasons for reliance on these drugs, to provide a detailed account that can be used by policy makers working on Antimicrobial Resistance (AMR) in Uganda today.

Using established social science methods, the team in Uganda provide fresh approaches to the study of antimicrobials in Ugandan society, to demonstrate how antibiotics are linked to social, economic, and political systems. Our research focused on antibiotics but also included antimalarials, antiretrovirals and antifungals. Project sites include Kampala, Wakiso, and Tororo.

How does social science contribute to the AMR research agenda in Uganda?

Social science research can assist in articulating the roles of antibiotics in everyday life in Uganda - for both people and animals- and in mapping their relationships to wider imperatives and infrastructures. This has helped reveal the wider effects that AMR pose, as well as informed potential consequences of policies to roll-back antimicrobial availability. With this knowledge, Ugandan policy makers can design policy tailored to our context in order to reduce the threat of AMR in Uganda.

Our research has focused on health workers and patients in Tororo district, with day-wage urban workers (factory workers, vendors, hawkers) in Nakawa Division, Kampala district, and in different scales of farming (piggery and poultry) in peri-urban Wakiso and rural Tororo district. It has also included detailed historical and archival research on Ugandan AMR policy guidelines, legal frameworks and regulations, both locally and globally, that will assist policy makers in charting future policy directions.

The AMIS Uganda project team consists of:

Ugandan Short Films

These short films show the AMIS Uganda research activities aimed at understanding the roles that antibiotics play in everyday life and the context within which antibiotics are used in rural Tororo, peri-urban Wakiso and urban Kampala.

The Antimicrobials in Society (AMIS) Project Uganda: A film about anthropological approaches to the study of antibiotic use for humans and animals in households and farms in rural, urban, and peri-urban settings in Uganda, East Africa.

Antibiotics as Hygiene: A film about antibiotic use in an urban informal settlement in Uganda 

No medicine, no life: A film about everyday life and use of medicines to relieve pain and enable productivity in rural households in Tororo district, Eastern Uganda 

Antibiotics as Protection: A film about antibiotic use in pig and poultry production in Wakiso district, Uganda

 

Online Hub
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The AMIS Hub is an online resource that has brought together research relevant to AMR from across different social science disciplines, throughout the AMIS project. Aimed at those designing and implementing AMR policy, as well as researchers from the life sciences, the AMIS Hub introduces readers to a wealth of relevant social research on AMR. The AMIS Hub materials include research summaries, commentaries, reviews of existing and ongoing research and theory and highlights relevant events. We envisioned the Hub as a mechanism for policy-makers and life scientists to engage with social science research on AMR, to forge future collaborations and to inspire new ways to address AMR.

Outputs
AMIS Publications
Use of antibiotics to treat humans and animals in Uganda: a cross-sectional survey of households and farmers in rural, urban and peri-urban settings
Susan Nayiga, Miriam Kayendeke, Christine Nabirye, Laurie Denyer Willis, Clare Chandler, Sarah G Staedke
2020
JAC- Antimicrobial Resistance
Social, cultural and economic aspects of antimicrobial resistance
Timo Minssen,Kevin Outterson, Susan Rogers Van Katwyk, Pedro Henrique D Batista, Clare I R Chandler, Francesco Ciabuschi, Stephan Harbarth, Aaron S Kesselheim, Ramanan Laxminarayan, Kathleen Liddell, Michael T Osterholm, Lance Pricel & Steven J Hoffman
2020
World Health Organization
Hunger will kill us before coronavirus does!
Susan Nayiga, Christine Nabirye, Miriam Kayendeke, Sarah G Staedke
2020
Social Science in Humanitarian Action Platform
Tuberculosis in the borderlands: migrants, microbes and more-than-human borders
Komatra Chuengsatiansup & Wirun Limsawart
2019
Palgrave Commun
The ‘Drug Bag’ method: lessons from anthropological studies of antibiotic use in Africa and South-East Asia
Justin Dixon, Eleanor MacPherson, Salome Manyau, Susan Nayiga, Yuzana Khine Zaw, Miriam Kayendeke, Christine Nabirye, Laurie Denyer Willis,Coll de Lima & Clare Chandler
2019
Global Health Action
The modern era must end: antibiotic resistance helps us rethink medicine and farming
Coll de Lima Hutchison, Gwen Knight, Richard Stabler, Clare Chandler
2018
BMJ
Anthropology’s contribution to AMR control
Laurie Denyer-Willis and Clare Chandler
2018
Addressing Antimicrobial Resistance through Social Theory: An Anthropologically Oriented Report
Clare I R Chandler, Eleanor Hutchinson & Coll Hutchison
LSHTM: Research Online
Antimicrobial Resistance & Anthropology
Chandler, C.I.R., and Hutchinson, C.
University of Bristol
Setting the standard: multidisciplinary hallmarks for structural, equitable and tracked antibiotic policy
Claas Kirchhelle, Paul Atkinson, Alex Broom, Komatra Chuengsatiansup, Jorge Pinto Ferreira, Nicolas Fortané, Isabel Frost, Christoph Gradmann, Stephen Hinchliffe, Steven J Hoffman, Javier Lezaun, Susan Nayiga, Kevin Outterson, Scott H Podolsky, Stephanie Raymond, Adam P Roberts, Andrew C Singer, Anthony D So, Luechai Sringernyuang, Elizabeth Tayler, Susan Rogers Van Katwyk, Clare I R Chandler
2020
BMJ Global Health 2020;5:e003091.