New Conceptions to Manage AMR – Part 2

Daniela Corno   

Urbanization is having an impact on antimicrobial resistance. According to the World Bank Group, today, more than half the world’s population lives in cities, and by 2050 nearly 7 in 10 people will be living in urban areas. But as our cities grow, so do the complex global health challenges they bring. 

My name is Daniela Corno, and welcome to another episode of Unpacking AMR.  

Last time Unpacking AMR brought you the first episode of our “New Conceptions to Manage AMR” series, a series that shines light on new conceptions put forward by social scientists with the goal of strengthening the next iteration of the global action plan on AMR. This plan aims to improve awareness of AMR, strengthen surveillance through research, reduce infection through better sanitation, hygiene and infection prevention measures, and improve funding to increase investment in new medicines, diagnostic tools, vaccines and other interventions. These new conceptions can help move the global action plan towards a more inclusive One Health approach.  

Today, we’re exploring antimicrobial resistance through the lens of urban political ecology, otherwise known as UPE. Imagine a large city bustling with life and opportunities. Streets are filled with people. New buildings are being built every day. Ecosystems are thriving amongst the backdrop of daily life, but if we take a closer look, we begin to realize that urban environments are not only where people live, but also spaces where politics, power and the environment clash in unexpected ways. This is where urban political ecology comes in. What does the way we build and live in cities have to do with the way bacteria resist antibiotics? And how can seeing those connections help us find better ways to address AMR?  

Today, I’m introducing two incredible guests who bring a unique one health perspective to AMR research and policy. First, we have Dr Raphael Aguiar, a postdoctoral fellow at the Dahdaleh Institute for Global Health Research, and along with him, we have Dr Kayla Strong, a Veterinary Epidemiologist and the research lead at our AMR Policy Accelerator at the Global Strategy Lab. Before we dive further into the episode, Raphael will walk us through what urban political ecology really is.  

Raphael Aguiar 

Urban political ecology can be understood as a concept or an approach to the social environmental emergencies of the 21st Century. UPE considers urbanization as both a space and a process mediating societal relations with nature. So think of urbanization mediating nature society relations, and by explicitly linking urbanization and environmental degradation in the face of climate crisis, emerging pandemics and threats to antimicrobial resistance, urban political ecology, or UPE, offers us a framework for a politics of sustainability and human nature relationships. Let me give some examples of that well before I start, it’s important to mention that UPE does not focus only on cities, but on urbanization forms and processes. It’s not a concern with separating cities and nature. UPE actually focuses on how nature is urbanized, and what does it mean for global health. It looks at how cities and landscapes are shaped and reshaped into landscapes of epidemiological or global health risks. It looks at how informal settlements, industrial livestock and agro-industrial production infrastructures increase zoonotic spillover risks. It looks at sanitation processes that control microbiological process through urban infrastructures. So if you think of UPE as an approach that looks at urbanization shaping nature society relations, we can focus on processes and forms relating to antimicrobial resistance and how, one way to see how this relates to AMR is to think about AMR not happening just in hospitals, but in urban environments as well, and UPE helps us think about AMR as not just a biological phenomenon, but one shaped by social, environmental and spatial inequalities. 

Daniela Corno   

As urban regions expand, they become hotspots for antimicrobial resistance, rapid population expansion, increased healthcare access and environmental factors can all create the ideal setting for resistant pathogens to spread. From the overuse of antibiotics in both humans and livestock to poor sanitation and pollution, urbanization plays an important role in driving AMR. 

Kayla Strong   

Urbanization doesn’t really just bring us physically closer together, but I would argue that it also changes the social, the economic and some of those ecological relationships. That also changes how antimicrobial resistance or AMR spreads, so our daily routines are increasingly involving shared touch points. For example, eating at restaurants, or using communal transport, or accessing health services in centralized areas high density clinics, or from kind of an anchor food systems perspective, we’re consuming food that’s been prepared far from where it’s actually being consumed or might be prepared in a restaurant setting. These are all kind of things that come to mind, and because at the same time, urban residents, they might be living side by side with animals, whether it be companion animals, where our relationship with them has really changed over the years, livestock, backyard livestock, or urban, urban wildlife. So I guess, to try and summarize it, these are really complex and kind of interconnected pathways that AMR can interact with cities. And it’s not just a clinical issue, it’s more of an urban systems issue. And then understanding how that AMR emerges and spreads in cities requires looking not just from a clinical perspective, but also looking at how power, infrastructure, livelihoods, urban design, and I guess that’s where a lens like urban political ecology really comes through. 

Daniela Corno   

As Kayla guides us through the pathways of AMR in urban environments, it’s important to consider how urbanization can shape the expression and visibility of existing inequalities. In low resource settings urban infrastructure may involve overcrowded housing or limited access to housing, clean water and sanitation. It’s easy to point to antibiotic overuse as the main culprit in places with high rates of resistance, when in reality, deeper issues like political, economic and governance systems may play a significant role in driving AMR. Take, for instance, an everyday chore of washing vegetables. This task can pose a higher risk of infection if someone lacks access to clean water, making them more susceptible to harmful bacteria. When infection happens, the need for antibiotics arises. 

Raphael Aguiar  

If you look at processes of urbanization, you’ll notice that it doesn’t happen in equal ways, so it’s in an inequal process. For example, people living in urban slums may lack clean water or access to healthcare, which leads to more frequent use or even misuse of antibiotics. On the other side, massive livestock operations outside cities may use antibiotics to boost productivity and these infrastructures, they may leak compounds into water systems that reach urban populations. So all these shape unequal AMR risks, and we can see how urbanization is a driver. 

Daniela Corno

From informal settlements with limited access to clean water and healthcare to industrial farming practices outside cities that affect the water we drink, these are all connected threads in the larger story of AMR. How can this lens help us understand who is most at risk of AMR in urban spaces and why some communities are more exposed than others. 

Raphael Aguiar Look at how people’s exposure to AMR risks are shaped by where they live, what kind of services they can access, and how urban systems, like ones that Kayla mentioned, such as housing, healthcare and sanitation, are managed. For example, someone in a well serviced urban neighborhood has far more protection against infection and also better access to regulated antibiotics than someone living in an informal settlement without clean water or functioning clinics. Looks at AMR as not just a matter of behavior or biology, but also looks at it as a structural issue, an issue of economic inequality, infrastructure gaps and governance failures. 

Daniela Corno 

The urban and political ecology lens concerns more than just humans living in cities. After all, cities aren’t just made up of humans. They’re also shaped by the way we produce food, manage animals and design infrastructure.  

Kayla Strong  

Urban political ecology, it’s inviting us to consider both animals and the environments in cities, not just as that biological aspect, but also in a political, social systems, and again, shaped by equality, governance, infrastructure. Some specific things that come to mind would be kind of this urban and peri-urban animal agriculture when we have growing populations, whether it be in the city or elsewhere, we have to intensify our food systems, and that’s especially the case for animal source foods, thinking poultry, beef, dairy, and when we have a greater concentration of animals in one place, similar to when we have a greater concentration of humans, there’s more potential for disease transmission. 

Daniela Corno  

AMR is a global health challenge. To address it, we need to recognize that this challenge affects human, animal and environmental health as well as the way that we produce and consume food. Cities rely on long, complex supply chains that touch everything from farms, to slaughterhouses to supermarkets, and each step along the way can create new risks for the spread of AMR. 

Kayla Strong  

This reflects, really the need for more antimicrobials, and we need those really to ensure both health and welfare of the animals. But it changes some of the antimicrobial risk. We also have these urban food systems and distribution chains, and I suppose, unlike rural settings, where your food might be grown in the same place that you process it, in the same place that you eat it. We have a lot of middlemen, or kind of intermediate stages that we go through, especially in the urban setting. It can be the farmers, it can be the transportators, it can be the processors, the retail before it reaches the consumer. Cities concentrate people and animals, but it also concentrates waste, wastewater from hospitals, farms, households, pharmaceutical industries, all of those might contain antibiotics, bacteria resistant, bacteria resistant genes. And in many urban settings, this waste enters the environment which might be untreated or partially treated. And I think this can create things like hot spots. 

Daniela Corno 

You’ve probably heard this kind of story in the news, eggs being recalled from your local supermarket because of concerns of salmonella. But what happens when we look at that problem through an urban political ecology lens? How might that change the way we understand the outbreak and the kinds of solutions we turn to?  

Kayla Strong  

Let’s say that there’s an outbreak of drugs resistant salmonella and chicken sold in a city market. If it was a traditional lens, I think I would look at the farm hygiene, or I would test the poultry for resistance. I would treat the poultry, and I would kind of make next steps going forward. I would argue in a UPE lens, we might ask some different questions. I think we would look at, who are these chickens being raised by, and where are they being raised? I would consider, are small scale producers using antibiotics because they’re lacking veterinary support? Do they have access to the right antibiotics that might be needed? Are they receiving the education about potential withdrawal times for those antibiotics? I would also look at if it might be connected to food security, for example, or informal economies or land access, and if those are having an influence on how the poultry health and the type of antimicrobial is being prescribed or being given. And then I suppose I’d also look at if markets are in lower income areas, if they’re more likely to face enforcement gaps. So are they getting tested the same way as those in a higher income area, for example. 

Daniela Corno 

When we hear about solutions to antimicrobial resistance, the narrative usually focuses on changing patient behavior, telling people to stop overusing antibiotics, improving prescription guidelines, or tracking resistance through surveillance. We need to zoom out in order to be able to see the big picture. This perspective of urban political ecology invites us to shift away to this broader approach. 

Raphael Aguiar  

Most AMR strategies today, they focus on surveillance, stewardship and behavioral change, what we sometimes call the biomedical fix, but this this approach, they don’t fully account for why antibiotics are overused in the first place. A UPE perspective would shift the focus upstream, looking at the root causes such as poor infrastructure, social marginalization, agricultural intensification and the global market pressures that accompany this intensification by including UPE for example, we can design AMR strategies that are more systemic, equity oriented and context specific. So it helps us recognize that addressing AMR also means addressing other social environmental issues such as climate change, other global public health threats, and social justice. 

Kayla Strong  

I think I would highlight that instead of just promoting stewardship or innovation, I think UPE really highlights the systemic change that might be considered so addressing housing, the sanitation, economic inequality and regulation and UPE really highlights that these are the people that need to be at the decision making table, not just your traditional doctors, veterinarians and government makers. I think the one other aspect that UPE really highlights, that I think is quite beautiful, is that it highlights the need for communities themselves to be at the table.  

Raphael Aguiar  

It shows how AMR is embedded in political economy that privileges efficiency and profit over sustainability and equity, and I’m thinking about human, animal and environmental health concerns. 

Kayla Strong  

So addressing AMR like Raphael said it’s not just about new drugs, but it’s about transforming cities and systems to be able to support that risk. 

Daniela Corno 

In the context of urbanization, concrete and transit lines are not the only things that make up a city. The unseen force of power and politics plays a key role, from the distribution of clean water to the accessibility of hospitals and the regulation of antibiotics. As we navigate this new conception, we must consider how power dynamics and political decisions sculpt the very fabric of our cities, influencing the risks associated with AMR. 

Raphael Aguiar Not just cities, but other forms of. Urbanization are also shaped by power and politics as much as by nature. In informal settlements, for example, people may not have access to licensed pharmacies or regulated healthcare, so they turn to informal markets, where antibiotics are sold over the counter without prescription. In some cities, hospitals and pharmaceutical companies, they discharge wastewater that contains antibiotic residues into public waterways. 

Kayla Strong  

I think of the health infrastructure in terms of where we’re building the hospitals, where we’re building the veterinary clinics, and where we’re even building the universities to support the involvement of that. So we know that if you build a medical school or a veterinary clinic, those cities have actually more veterinarians or more doctors available, and I think that there’s a lot of decisions about where those invested and that, again, is political, and there’s a huge power dynamic behind that. 

Daniela Corno 

We’ve heard how antibiotics move through food systems, how hospitals and waste carry risks and how marginalized communities often bear the greatest burden. Now let’s look into the future. If we reimagined cities that were designed with AMR in mind, what would this look like? 

Kayla Strong  

In my perspective, I would ensure equitable access to healthcare, and I mean that in both a human and animal setting, so people don’t rely on informal or unregulated antibiotics, or if they are doing so, to have the education and resources available for them to safely ask questions. I would also really invest in sanitation, waste management and clean water systems bringing in that WASH component. Finally, zoning laws that reduce risky cohabitation of livestock and people in dense areas is something I personally would want to look into, but I want to do so carefully. I want to make sure that people’s food security is not at risk. In terms of who’s involved, I think local communities, especially those most affected by poor health and sanitation, are at the decision making table. 

Daniela Corno 

It’s key that prevention, equity and infrastructure work together in harmony, all using a One Health approach. This means really focusing on solutions that reshape the very same environment where people, animals and nature co exist, while simultaneously making sure those most affected are part of the conversation. 

Raphael Aguiar A city that invests in public infrastructure to reduce people’s dependence on antibiotics by tackling the underlying drivers of disease such as poor housing, food insecurity, environmental contamination, a city that regulates harmful practices in agriculture, pharmaceutical production and industrial waste management, but most importantly, it will be a city that is envisioned and built on participation and equity. That means including communities, especially those most affected by AMR in the decision that shaped their environments. It means recognizing that expertise isn’t just something that lives in universities or ministries, but also in neighborhoods, clinics and community groups and in terms of people involved, I’d say that this will be diverse, including urban planners, public health professionals, veterinarians and environmental scientists, but also community organizers, farmers and civil society organizations, I think everyone has a role to play. And I think also tackling AMR isn’t just a medical issue, it’s a question of what kind of society we want to build.  

Daniela Corno 

That was Dr. Raphael Aguilar, postdoctoral fellow at the Dahdaleh Institute for Global Health Research, and Dr. Kayla Strong research lead at the Global Strategy Lab. Thanks for tuning in to another episode of Unpacking AMR. To find more resources about the topic we discussed today, visit our podcast page at www.globalstrategylab.org/UnpackingAMR. And remember, AMR is more than drugs and bugs!