The AMIS Project Thailand is an anthropological research project aimed at better understanding the role of antimicrobials in daily life in Thai society in diverse contexts and with different actors, including health care providers, day wage urban workers, scientists and policy-makers. The research focuses on the ways in which antimicrobials enable particular ways of life, livelihoods and institutional practices, and explores the context and the wider motivations for antimicrobial use in Thailand. Specifically, it focusses on access to antimicrobials in community pharmacies in Thailand, the transmission of antimicrobial resistant infection in bedridden patients, and the impact of rational drug use policies.Our use of antibiotics has escalated. We are often most aware of antibiotic use when we treat infections - for people, and animals. However, their use is more widespread. We use them routinely to reduce risks of infection amongst people with vulnerable immune systems, in farming livestock, to manage infection and to promote growth and even in crop farming. This widespread use is linked to a rise in antibiotic resistance (AMR). The amount of antibiotic chemicals in circulation is held responsible for driving selection pressure amongst bacteria such that some infections become untreatable with previously effective drugs. This can have dramatic consequences for both health and economics. And yet, scientists have emphasised the lack of evidence for using antibiotics in many scenarios. For example, it is estimated that at least 50% of human antibiotic usage has no clinical benefit. Policy makers are agreed that we must reduce our reliance on these medicines. But how? Efforts to change end user behaviour are often called for but thus far have not had the widespread impacts required to curb the emergence and spread of resistance. In this research, we propose that antibiotics are embedded within our socioeconomic infrastructure in such a deep way that attempts simply to change behaviour of patients, physicians or farmers are peripheral to our underlying dependency on their use. We suggest that by understanding the ways in which antibiotics are intertwined with our lives, institutions and infrastructures today we may identify ways to replace their use while minimising unintended consequences. For example, attempts to reduce use of one antibiotic often increases the use of another. Removing antibiotics all together may require a more systemic intervention such as the promotion of recovery time. In so-doing, however, other consequences could occur for the workforce and for economies tied up with pharmaceutical production and sales. We need to look closely at measures that have already been taken to reduce antibiotic use and understand what their consequences have been, as well as play out potential new interventions in different settings. If we are able to identify effective measures to reduce reliance on antibiotics in different scenarios, this will be more cost effective and timely than one-size-fits-all efforts to change end user behaviour. The issue of AMR is global, and is expected to have most severe consequences for low and middle income countries (LMICs). The need to reduce use of antibiotics in these settings presents a particular challenge, where markets fill the gaps of fractured health systems. An access-excess balance is described whereby many in need of antimicrobials remain untreated while these medicines are commonly used unnecessarily. This scenario persists despite decades of research and programmes into the rational use of medicines in LMICs. New approaches are needed to uncover the significance of antibiotics in our societies, to understand why the imperative to target their use so difficult to enact. This project presents a fresh approach beyond the traditionally delineated domains of social, biological or clinical sciences. The project aims to launch the AMIS Hub, an internationally recognised centre of excellence for developing, implementing and disseminating high quality research on antimicrobials in society, and two initial studies in Thailand and Uganda with the following objectives: 1) To understand the roles of antibiotics in every-day life and infrastructure 2) To evaluate the impact on care of imperatives to restrict antibiotics 3) To identify and rehearse counterfactuals to antibiotic use. This project will generate a critical mass of researchers undertaking high quality research into AMR, high quality comparative evidence indicating the nature of our reliance on antibiotics and recommendations for alternatives to antibiotics that will minimise unintended consequences.

Ethnographic fieldwork was conducted between August 2018-November 2020 and included qualitative interviews, focus groups, participant observation, a household drug survey, and health facility mapping. A total of 89 semi-structured and informal interviews were conducted with 47 informants. Informants were recruited using a purposive sampling strategy designed to include stakeholders with a range of roles and perspectives on antimicrobial use in Thailand. Interviews were conducted face-to-face or remotely online or via telephone and lasted between 40-60 minutes. Three focus group discussions were conducted with community health volunteers, working age and elderly residents, recruited via the sub-district health promoting hospital. Participant observation was conducted in two privately-owned community pharmacies and with 27 bedridden patients and their relatives. A household drug survey was conducted in 95 households across three communities in the sub-district. The survey included four sections: demographic information; health status; household medicines; medicine storage. Follow-up questions were used to elicit further details about antibiotic access and use. In addition to ethnographic and survey data, key legislation and policy documents were reviewed to contextualise ethnographic fieldwork.