The AMIS Project Uganda is an anthropological research project aimed at better understanding the use of antimicrobials in Ugandan society. The study used a mixed-methods approach to investigate the roles and context of antimicrobials in daily life in Tororo, Wakiso and Kampala districts from the perspective of health care providers, farmers and day wage urban workers. The data collection includes field-note and contact summaries, in-depth interview transcripts, key informant interview transcripts, medicines surveys, oral histories, and participant feedback dialogues.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 of 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.

This study used an observational mixed-methods research design. Fieldwork was conducted in blocks of 6-10 weeks over a period of 24 months between 2018 and 2021. This included: 1) 51 semi-structured interviews with key informants, including healthcare providers, farmers and day-wage workers to understand how antibiotics are intertwined in people’s lives; 2) 12 stakeholder interviews with policy makers, public health practitioners, regulators, consumer groups, NGOs, and researchers to better understand AMR policies and initiatives; 3) long-term participant observation with 73 individuals; 4) Medicines surveys involving 609 participants to capture and explore patterns of antibiotic use for humans and animals. In total, 733 individuals were engaged during fieldwork across the three sites. The semi-structured interviews were based on pre-defined topic guides to investigate the ways in which antimicrobials enable particular ways of life and livelihoods, as well as the wider reasons for antimicrobial use in Uganda. Participants were identified using a combination of purposive and snowball sampling techniques to enrol a wide range of stakeholders related to antimicrobial use. Following informed consent, the interviews were audio recorded and later transcribed and translated into English. In addition to ethnographic fieldwork, documentary analysis was conducted to identify relevant public health literature, policy documents, and media materials, to contextualise ethnographic findings. Participatory research activities were also conducted to elicit preliminary feedback on findings from research participants. This included 10 feedback dialogue events, engaging 123 individuals.