Written by Dr. Laurie Denyer Willis and Dr. Clare I.R. Chandler
This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.
A key global health objective related to antimicrobial resistance (AMR) is to reduce antibiotic use. Many interventions to lower antibiotic use are based on models of behavior change. Our extensive ethnographic research over 10 years in East Africa shows why these interventions often have limited impact.
We found that antibiotics are often used as a “quick fix” – they paper over underlying structural issues related to marginality, inequality, violence, health systems and infrastructures. Antibiotics can be understood as a quick fix for care in fractured health systems; for productivity at local and global scales for humans, animals and crops; a quick fix for hygiene in settings of minimized resources; and a quick fix for inequality in landscapes scarred by political, economic and post-colonial violence.
Understanding antibiotic use in this context requires shifting attention to the structural dimensions that antibiotics are currently fixing, like equality, care, hygiene and increasing demands for productivity. These dimensions tend to be obscured when following an individual behavior change approach – often going unaddressed when antibiotic use is described in the language of “good” and “bad” behavior.
It is important to appreciate the extent to which daily life has become intertwined with antibiotic use to understand the consequences of resistance and the best ways to reduce the threat of AMR. This is particularly true in low- and middle-income countries, where antibiotics are put to work to correct deficient infrastructures of care, water and sewage, hygiene and demands for ever-increasing productivity.
We can connect this entrenched use of antibiotics to neoliberal reforms, the legacies of structural adjustment programs and the marginalization of the poor and vulnerable. For them, antibiotics have made life liveable in contexts of scarcity, uncertainty and inequality.
During our fieldwork in Uganda we met Grace, who lived in an urban settlement in downtown Kampala. The few fee-for-use latrines were filthy. Most people could not afford them or avoided them, choosing instead to use buckets or polythene bags for toileting, and then disposing their waste either in drainage channels or rubbish piles.
The channels are the same ones people use to wash clothes and take water for their livestock and gardens. During heavy rain, they overflow into homes, gardens and livestock pens.
Many adults and children in the settlement live with chronic diarrhea and abdominal pain. Grace showed us her plastic basket of medicines she keeps at home. It was a small collection of Panadol (paracetamol), some amoxicillin tablets and a full box of metronidazole.
Antibiotics make unavoidable diarrhoeal disease bearable, enabling people in the settlement to carry on with life. There is little political will to tackle these issues, as the local press describes the settlement as a problematic “slum” and those live there as “illegal squatters” and criminals.
Low-income and middle-income countries have been identified as a specific target for AMR and antibiotic use policies due to a range of factors that locate them as particularly vulnerable to the effects of AMR, as well as the perception of them as posing a risk to other countries through the connectivity rendered so apparent in previous pandemic scares.
Recognizing many of our AMR solutions as quick fixes allows us to raise our line of sight to the longer term, generating more systemic solutions that have greater chance of achieving equitable impact.
To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings), visit savethechildren.org.