by Christie Cabral and Helen Lambert
Anti-microbial resistance (AMR) is a ‘wicked problem’ leading to drug resistant infections. The evidence is incomplete or contradictory, there are many different interest groups with different needs and views, and the ‘solution’ depends on how the ‘problem’ is framed and vice versa. Like other ‘wicked problems’ (e.g. climate change, species conservation, pandemic influenza) that result from the complex interaction of a huge range of influences, there is no single, simple solution and so our response needs to be multifaceted.
Leonardo Da Vinci, one of the best known polymaths, excelled in different artistic and scientific fields long before we had separated these activities out into the numerous disciplines we have today. This boundary-crossing approach is what is called for by the Cross-Council Initiative to tackle antimicrobial resistance.
Inter-disciplinary research is often under-funded and poorly regarded but it is essential “to solve the grand challenges facing society”. The Cross-Council Initiative is a rare call for everyone from Artists to Veterinary Scientists to work together on the problem of AMR.
So far, a lot of attention has focussed on possible technological solutions (such as new antibiotics and rapid diagnostic tests), but key work by the O’Neill Review team has rightly highlighted the importance of understanding economic processes. These underline the ‘wicked’ nature of this problem, as the needs and views of stakeholders are not aligned. Pharma companies want to maximise profits, but governments want to restrict the use of new antibiotics to preserve their effectiveness – so the pharmaceutical industry cannot recoup the costs of developing them through sales. The O’Neill Review recommends other financial mechanisms to encourage the pharmaceutical industry to develop new drugs that can be reserved for use when current ‘last resort’ antibiotics become ineffective.
But improving the likelihood of future technological innovations can only ever be part of a solution. When, how and why people use existing antibiotics unnecessarily – for themselves or their animals – are problems that can’t be tackled through drug or diagnostics development. For many people around the world, especially in lower and middle income countries, the problem is not so much too many antibiotics as insufficient access to them. The tension between access and excess is another dimension of the ‘wickedness’ of the problem; seemingly obvious solutions, like banning over-the-counter antibiotics sales in low-income countries, risk denying essential life-saving drugs to the poor, who lack easy access to decent medical care where they can be prescribed appropriate antibiotics when needed. Here social science is needed to understand the complexities of human behaviour and the cultural, social, institutional and political forces that shape it, as well as individual psychology. This way we can gain insights into ways to ensure that people get access to these life-saving drugs when they need them, while not using them unnecessarily so that infections become resistant to them.
The ESRC-led Theme 4 of the Cross-Council Initiative is entitled ‘Behaviour within and beyond the health care setting’. As we saw at our recent Social Science and AMR workshop (#amrchamp), potentially relevant research covers a broad range of topics. When social scientists get together, some interesting questions get asked: what types of drug resistance are a problem, in which contexts and for whom? Issues of justice and future security are highlighted by international relations researchers looking at the unequal balance between access to antibiotics and the development of drug resistant infections across the globe. Geographers, sociologists, environmental and veterinary scientists are looking at how our environments are entangled and the poorly understood microbiological pathways and social networks by which resistance is spread, without which we cannot know which ‘human and animal behaviours’ it might be sensible to target. Artists and engineers are exploring how to design infection control into our world and how to communicate important messages to the wider community.
We come back to the ‘wicked’ nature of the issue. The way the ‘problem’ is framed is important to how we tackle it: excessive use, or lack of access; public demand, or market-led health systems that incentivise medical practitioners to overprescribe; international travel, or locally occurring ‘pockets’ of resistance; lack of incentives for commercial pharmaceutical production or lack of non-profit making alternatives for developing new drugs; medical/veterinary overuse, or environmental contamination?
The Theme 4 call is an opportunity for truly interdisciplinary research involving biological, medical and social scientists, engineers and artists. Thinking and acting collaboratively is perhaps the only way we might truly be able to tackle this wickedly complex problem.