This week saw the publication of another research paper presenting evidence of ‘social’ drivers of antimicrobial resistance. Mark Caudell and colleagues’ ‘Identification of risk factors associated with carriage of resistant E. coli in three culturally diverse ethnic groups in Tanzania: a biological and socioeconomic analysis’ follows on the heels of Peter Collignon and colleagues’ paper on ‘Anthropological and socioeconomic factors contributing to global antimicrobial resistance’, also published in the Lancet Planetary Health a few weeks ago. The papers investigate AMR at different scales but, interestingly, reiterate a similar interpretations of resistance drivers. Where Collignon et al. illustrate at a macro level in their cross-country analysis that transmission factors seem more important in driving AMR than amount of antimicrobial use (AMU), Caudell et al. also identify transmission as key but at a local level, and find that household antimicrobial use plays less of a role – specifically in E. coli resistance.
 
In both cases, the authors identify social factors as key drivers of resistance. The macro-level paper identifies governance – analysed as a national corruption index – as well as infrastructure such as sanitation as key. This is mirrored in the findings of the micro-level paper that the ways water is accessed and how milk is handled are key to the transmission of resistant E. Coli. It is tempting to imagine that behavioural change presents a solution when analysing hygiene and sanitation as social practices. However, when coupled together, these papers highlight the importance of recognising the wider infrastructural systems involved in effective sanitation.
 
As Helmut Bürgmann and colleagues have written this week, numerous questions around sanitation systems remain, including the microbial ecological processes occurring within waste water treatment – and the extent to which they attenuate or amplify AMR. Reading historian Scott Podolsky’s recent paper ‘The evolving response to antibiotic resistance (1945-2018)’ reinforces how relatively recently our attention has begun to focus on wider structural issues in sanitation and hygiene when addressing AMR. As we continue to see the arena of research on the drivers of AMR developing, it is therefore most encouraging to see multidisciplinary teams grappling with the challenges of tracing resistance both through finely grained local analyses and at the macro-level. The next challenge will be to connect these, and to take seriously the tasks of infrastructural change that seem likely to be required to enable a world in which AMR is no longer a spectre.