HOW POVERTY CONTRIBUTES TO ANTIMICROBIAL RESISTANCE

OVERUSE OF ANTIMICROBIAL DRUGS CREATES DANGEROUS RESISTANT STRAINS OF MICROORGANISMS. YET IN SOME PLACES OF THE WORLD TODAY, IT IS IMPOSSIBLE TO GET BY WITHOUT THEM. MEDICAL ANTHROPOLOGISTS OF THE LONDON SCHOOL PROFESSOR CLARE CHANDLER AND SUSAN NAYIGA, OF HYGIENE AND TROPICAL MEDICINE IN THE UK, STUDY HOW CONDITIONS IN UGANDA FORCE RESIDENTS TO RELY ON ANTIBIOTICS ON A DAILY BASIS

TALK LIKE A MEDICAL ANTHROPOLOGIST says Clare. The problem is a global one, as ANTIMICROBIAL DRUGS – drugs that MULTIMORBIDITY – multiple conditions resistant strains bred in one small region can kill or suppress the growth of bacteria, that combine to create ill-health quickly travel around the world thanks to the fungi, viruses and other microorganisms interconnectedness of modern life and the in or on the human body, other animals PARTICIPANT OBSERVATION – an world economy. or plants anthropological data collection method in which researchers join in with the activities But reducing antimicrobial use is easier said than ANTIBIOTICS – a type of antimicrobial of the people they are studying in order to done. Many people have good reasons to rely drug that kills or suppresses the growth observe through experience on antibiotics in the short term, even if doing so of bacteria increases the risk of superbugs in the long term. ‘ONE HEALTH’ APPROACH – an Medical anthropologists like Clare and Susan ANTIMICROBIAL RESISTANCE approach to health that combines diverse study how people interact with medicines. They (AMR) – the ability of microorganisms academic disciplines and considers animals, use their research findings to help policy-makers to survive antimicrobial drugs due to plants and the environment as well develop policies that allow people to live with less evolutionary adaptations gained through as humans reliance on antimicrobial drugs. repeated exposure to these drugs ANTHROPOLOGICAL METHODS To study antibiotic use in rural and urban Uganda, Clare, Susan and the AMIS team used Antibiotics have transformed human life. difficult choices local people face when it comes a method called ‘participant observation’. They Infections that once killed millions can now be to health and work. spent extended periods of time living with the cured by taking a few tablets. Yet this miraculous communities they were studying, getting to know technology contains the seeds of its own THE PROBLEM OF how things are done and what day-to-day life is destruction – the more we use antimicrobial ANTIMICROBIAL OVERUSE like, immersing themselves in the local culture to drugs, the more microorganisms evolve, adapt Antimicrobial drugs have many important uses. understand the rules, the local community’s idea and become resistant to them. Overuse of They cure and prevent infections in humans, of common sense, and how people respond to antimicrobials can breed dangerous ‘superbugs’ animals and even crops. However, they have challenges within their cultural context. immune to any treatment. As a result, the come to be used in cases beyond the strictly United Nations considers antimicrobial resistance medically necessary. For example, people might They also used surveys and ‘medicine bags’ to (AMR) to be a global high priority health issue use them to increase livestock productivity and as discover how people interact with antibiotics. and recommends reducing antimicrobial drug use. a quick fix to stop infections, rather than avoiding “Rather than asking ‘do you use antibiotics?’ infections in the first place through better which might be interpreted differently by But why do we overuse antibiotics, and why is hygiene and sanitation infrastructure. different people, we showed people packets of it difficult to stop overusing them? With the locally available antibiotics,” explains Susan. “We Antimicrobials in Society (AMIS) project, As human use of antimicrobials has increased, asked them to sort them into piles of medicines Professor Clare Chandler and PhD researcher microorganisms have adapted and evolved to they recognised, medicines they used frequently Susan Nayiga of the London School of Hygiene become resistant to these drugs. “It has been and medicines they don’t know. This helped us and Tropical Medicine are studying antibiotic estimated that by 2050, 10 million lives a year to understand the significance of medicines in use in rural and urban Uganda, highlighting the could be lost due to drug-resistant infections,” people’s lives.” In addition to gathering data from communities, do not have the money to access facilities or the Susan and Clare put what they learnt into power to demand better infrastructure. They PROFESSOR historical and political context. By examining deal with poor health caused by lack of sanitation CLARE CHANDLER past policy documents and evaluation reports, by taking small doses of antibiotics, sometimes Professor in Medical Anthropology they were able to trace the influence of different forgoing food in favour of medicine. Residents London School of Hygiene and Tropical local, national and international programmes must remain well enough to work or they will be Medicine, UK and policies that had attempted to improve the unable to afford basics like food. health of particular populations. “Our analysis pulled together different threads of research, Susan recounts that “in Kampala diarrhoea was weaving together narratives that could describe common and there was frequent use of antibiotics and explain what we were seeing about antibiotic in anticipation of diarrhoea almost every week.” use in everyday lives,” says Susan. This approach This level of antimicrobial use contributes helped them understand why people use certain to AMR, but simply targeting antibiotic use medicines and why they must rely on antibiotics reduction fails to address the root causes of instead of avoiding infections through hygiene and overuse in these communities – poverty and lack infrastructure. of access to hygienic facilities. Policy-makers in local, national and international governments ISSUES IN RURAL AND URBAN must address these infrastructural issues in order UGANDAN COMMUNITIES to reduce the risks from AMR. Clare and Susan investigated antimicrobial use in two communities in Uganda. Nagongera is a HOW LINKING POVERTY TO ANTIBIOTIC SUSAN NAYIGA rural village in Tororo District, while Namuwongo USE IN UGANDA CAN HELP PREVENT is an informal settlement (also called a ‘slum’) GLOBAL SUPERBUGS PhD student, London School of Hygiene in Kampala, the capital of Uganda. In both Clare and Susan hope that their research will and Tropical Medicine, UK communities, residents struggle with food poverty help global policy-makers address the causes of Researcher, Infectious Diseases Research and access to clean water and public health antimicrobial overuse. “We have promoted the Collaboration, Kampala, Uganda infrastructure. concept that antibiotics are ‘infrastructural’, meaning that they are not only a part of the fabric FIELD OF RESEARCH In Nagongera, water is available from wells and of our health systems but also our societies,” boreholes. The boreholes are a source of clean says Clare. Medical Anthropology water, but the monthly access fee is more than many residents can afford. Instead, they Awareness of why people overuse antibiotics must collect drinking water from wells that are highlights how merely restricting the use of these RESEARCH PROJECT contaminated by animals and potentially human drugs is unlikely to be effective and will in fact Understanding how rural and urban waste. People in Namuwongo also lack reliable harm struggling communities. Instead, providing communities in Uganda interact with access to safe water, as water sources become access to clean water and public latrines in antibiotics as a foundation for tackling contaminated during the rainy season. communities such as Nagongera and Namuwongo global antimicrobial resistance would make constant use of antibiotics In both communities, most households do not unnecessary, improve public health and quality of have access to a private latrine. Public toilets are life in these communities and lower medical costs FUNDERS available in the urban settlement of Namuwongo, for residents. Not only that, but antibiotic use but they are expensive to use and are closed at in Uganda is a global problem, not a local one, as ESRC, DHSC, GCRF The Antimicrobials in Society (AMIS) grant was night. As a result, people are forced to use bushes, drug-resistant microbes can quickly spread across awarded by the Economic and Social Research buckets and polythene bags as toilets. Residents the world. That makes poverty and lack of public Council (ESRC) on behalf of the Antimicrobial are warned by public health campaigns to boil health infrastructure in Ugandan slums a global Resistance Cross Council Initiative supported by the seven research councils of UK Research Innovation water before using it for cooking or drinking, but problem, too. (UKRI) in partnership with other funders [ES/ they do not always have the money for fuel or the P008100/1] time to boil water for multiple uses throughout Clare and Susan’s research highlights the the day. important contributions medical anthropology economic systems. Medical anthropologists forge can make on many levels. Advances in medical links between these different domains, allowing Lack of clean water and sanitary facilities leads technology are not enough to solve global public holistic solutions to be found in a ‘one health’ to diarrhoea and water-borne diseases. Although health issues because medicines are used by approach that help to solve pressing, real-world residents know why they are getting sick, they people and distributed by human political and problems that affect us all. Houses in Namuwongo, Kampala

ABOUT MEDICAL ANTHROPOLOGY

WHAT IS MEDICAL ANTHROPOLOGY? and migration lead to an increase in WHAT DOES THE FUTURE HOLD FOR Medical anthropology is a branch of multimorbidity, with multiple conditions MEDICAL ANTHROPOLOGISTS? anthropology – the study of humans, and combining to create ill-health. Medical There is growing interest in medical how humans live together in the world. anthropology has been critical in informing anthropology due to recent events like the Medical anthropologists study health, illness understanding of the conditions and drivers COVID-19 and Ebola crises, the growth and medical systems. This includes the social of both infectious and chronic diseases. It has of the anti-vaccination movement and the processes, rituals and meanings around health been instrumental in directing preventative threat of antimicrobial resistance. “This means and illness, western and traditional medicines, action as well as responding to epidemics and anthropologists are having to find ways to different medical systems, and death and dying. longer-term health crises. The ability to link communicate about their research more social, economic and political dimensions to with the general public as well as with people WHY DO WE NEED MEDICAL distributions, conditions and experiences of ill working in decision making positions,” says ANTHROPOLOGY? health is critical in informing understandings Clare. “Future generations will advance our The health of people around the world and responses. Anthropologists are now methodological toolkits to address changes in continues to face challenges, with many commonly involved in health planning, health anthropology and to enhance the ways that we infectious diseases that take a serious toll systems and health response teams on both come to know and communicate about topics on peoples’ lives – including drug resistant national and international stages. of study.” infections. Ageing populations, urbanisation

EXPLORE A CAREER IN MEDICAL ANTHROPOLOGY

The Royal Anthropological Institute has great learning PATHWAY FROM SCHOOL TO resources and events for people interested in a career in MEDICAL ANTHROPOLOGIST anthropology: www.discoveranthropology.org.uk “At school and college, any of your subjects will help towards Medical anthropologists may work in academic institutions learning about anthropology later on,” says Clare. “At university conducting research, like Clare and Susan. There are also you can study straight anthropology, or with archaeology or human career opportunities in industry and the public sector, for sciences.” Specialisation in medical anthropology will usually occur at example as health care consultants, health policy analysts or postgraduate level. health services directors.

CLARE AND SUSAN’S TOP TIPS

CLARE: Follow your passions and make it count! Work hard, with focus, and forge your own path.

SUSAN: Work on your dream every day. With hard work and perseverance, you will achieve it.

A homestead in Tororo district HOW DID CLARE BECOME A MEDICAL ANTHROPOLOGIST?

When I was younger I was interested in I didn’t deliberately become a researcher – I and I enjoy walking and cycling. But most of why people lived differently in different didn’t plan it, and I’m rather surprised to find my out-of-work time is spent with my children places. I was fortunate to spend time in myself as a university professor! The way I who continue to inspire me! West Africa as a child and was fascinated by think was inspired by my father, who was an the comparison between life in rural Sierra engineer working on rural telecommunication I was really proud to be awarded the Woodruff Leone compared with life in a cosmopolitan systems, and I liked his methodical approach to Medal for my PhD. It is awarded each year area of England. I was struck by the ways working out problems. I was more interested in to someone whose thesis has an impact on that histories of different places meant that people than technology and went on to study medicine. I was really pleased my research was life, values, political priorities and health anthropology. recognised in this way, especially as I was an could be so different depending on where anthropologist rather than a medic. you lived. I love music – I play violin and enjoy singing,

HOW DID SUSAN BECOME A SOCIAL SCIENTIST?

When I was younger I was interested in I was offered a government scholarship I was proud to attain a PhD scholarship at people that were vulnerable and I aspired to to study social sciences at university. I the London School of Hygiene and Tropical give a voice to those who were oppressed. had the opportunity to be part of research Medicine. The field is dominated by medical I spent my early life in Eldoret, Kenya, teams which played a big role in shaping scientists so I never imagined that, as a during the 1980s due to civil war in my my interest in social aspects of community social scientist, I would be considered for home country, Uganda. As a child, listening healthcare. It was most exciting to get a job such an opportunity. I was proud to be the to the stories told by my parents about the with a malaria research project after leaving first social scientist in my organisation to suffering of relatives and friends back home, university, which marked the beginning of be offered this scholarship. After, I hope I was fascinated by their stories about life, my career as a social scientist. to join an academic institution to engage survival and escape. in teaching and continue to conduct social I enjoy playing golf and spend most of my science research. My journey as a researcher started when free time doing that.