New Conceptions to Manage AMR – Part 3 – Infrastructure

Daniela Corno 00:23

Antimicrobials are medicines that prevent or treat infections caused by bacteria, viruses, fungi and parasites. They are one of the most important tools in modern health, allowing us to safely manage infections that were once life threatening.

When we think about antimicrobials, many of us picture a biomedical story, one that unfolds in hospitals and clinics. Physicians prescribing antibiotics, pharmacists dispensing them, or patients taking them to recover from infection.

But antimicrobials go far beyond hospitals and pharmacies. They are woven into the very systems that support modern life. In food production and animal health, they help manage disease and support welfare in livestock and companion animals. In our water, sanitation, and hygiene, otherwise referred to as WASH, infrastructure, they can compensate for weak WASH systems. Across medical procedures, transportation systems, and even global trade, antimicrobials quietly underpin much of what we rely on every day. Like the pipes that bring us clean water or the grids that power our homes, antimicrobials have become part of our essential infrastructure.

When antimicrobials move through human, animal, and environmental systems, they shape how microbes evolve. This is where antimicrobial resistance (also known as AMR) comes in—a natural process where microbes find ways to survive antimicrobial exposure. But while AMR is part of microbial evolution, the way we use antimicrobials can speed it up. When antimicrobials are overused or used in the wrong situations, whether in food production, health care, or everyday settings, we create more opportunities for microbes to adapt and share resistance. In other words, our practices don’t create AMR out of nowhere, but they can accelerate how quickly it develops and spreads across communities, animals, and the environment.

My name is Daniela Corno, and welcome to another episode of Unpacking AMR. This is the third episode in our new conceptions to manage AMR mini-series, a series that explores how social science can reframe the way we think about antimicrobial resistance and strengthen the next global action plan.

Today, we’re looking at AMR through the lens of infrastructure—shifting our focus from microbes to the systems that make us dependent on antimicrobials. This perspective highlights the often-overlooked ways antimicrobials fill gaps in care, sanitation, and everyday routines, revealing how structural weaknesses drive their overuse.

To help unpack this idea, I’m joined by Dr. Clare Chandler, Professor of Medical Anthropology at the London School of Hygiene and Tropical Medicine, and Dr. Susan Nayiga, Research Fellow at the Infectious Diseases Research Collaboration in Kampala, Uganda, and the London School of Hygiene and Tropical Medicine.

Let’s kick things off with some comments from Dr. Chandler.

Clare Chandler 03:10

So for me, the idea of understanding antimicrobials, that would be antibiotics and other kinds of medicines that we use for dealing with infections. The reason that I think it’s useful to think about them as infrastructural is that they’ve become so much part of our everyday life. They’re like the woodwork. They’re the things that we don’t see, but that help things to go around. And that’s not necessarily to say that that’s a good thing or that’s a bad thing. It’s just something that we’ve taken for granted, that they’re there. We use and we’ve kind of intertwined these antimicrobials in multiple different aspects of our lives.

We didn’t use to think about it so much, perhaps, because they were working. So we started to embed antimicrobials across different scales of production, across medicine, in lots of different fields. In cancer treatment, we use them to prevent infections, or, you know, to treat infections if they come up very early, so that we then prevent infections from getting more serious, which could happen if you’re immunocompromised. We use them together with cancer treatment, together with other forms of treatment for people with immune compromised diseases. But we also use them in agriculture and in other areas where we’re trying to ensure you know particular productive outputs in a more reliable way.

Daniela Corno 04:54

Antimicrobials are not just tools for healing. They’re the essential systems that hold much of modern life together, from farms to hospitals, they keep things running smoothly and, in some cases, efficiently. But what happens when that essential system starts to fail? As resistance grows, the scaffolding that once held everything in place begins to show its cracks, revealing just how much we’ve come to depend on these medicines in ways we may have been taking for granted.

Clare Chandler 05:20

So for me, thinking infrastructurally helps us to continue to look for those different places and the different ways that we rely on them, that perhaps we haven’t been thinking about and that we need to attend to as we look forwards to a future in which we hope to have less resistance, but which we know will continue to see a rise in resistance and that we need to be prepared for.

Daniela Corno 05:45

Around the world, and especially in low resource settings, individuals and institutions may rely on antibiotics to cope with gaps in sanitation, healthcare, and everyday routines in Uganda. Dr. Susan Nayiga has spent years studying how communities and health facilities navigate this dependence. She describes how antimicrobials have come to play roles far beyond their original purpose, not only treating infections, but holding together routines, livelihoods, and even institutions.

Susan Nayiga 06:16

When I think of infrastructure, I sort of think of the role that antibiotics or antimicrobials play beyond their original medicinal role, the roles that enable everyday routines in our societies and also maintain some sort of stability in people’s everyday lives, and examples of the way this plays out in health systems, we see the reliance on antibiotics to manage infections, but also from the research we’ve done over the years looking at how individuals depend on antibiotics to cope with the various insecurities in their everyday lives, such as the lack of access to clean water, poor sanitation and hygiene facilities, but just even having to continue to work and taking an antibiotic to ensure you can keep going and deal with your health challenges over long periods of time.

And I think when I think of infrastructure as well. I think of institutional dependencies on these medicines that have formed around the availability of antimicrobials, as an example, in one of our research studies in Uganda, we noted in this study where we were doing work in rural health facilities, we observed that when medicines were not available, when there was a stock out of medicines, and even mainly antimicrobials, everything almost came to a standstill at the health facility.

Daniela Corno 07:57

Medicine stock outs causing entire health facilities to slow down. It shows just how deeply these drugs are woven into keeping systems operational. But this reliance comes with tradeoffs, while antibiotics can shore up gaps in healthcare, hygiene and daily routines, leaning on them too heavily carries serious risks. Antimicrobials can act as a kind of “quick fix”, temporarily patching over structural weaknesses when the drugs fail, either because of resistance or limited supply, the underlying problems they were masking are suddenly exposed.

Susan Nayiga 08:30

In low resource settings the challenges that we often grapple with are limited access to good quality health care, limited access to quality antimicrobials. There’s a challenge of weak regulatory systems, poor health infrastructure, poor sanitation facilities, which often exacerbate the unnecessary use of antibiotics and drive resistance. And I think when we think of solutions, we think more towards investing in systems, strengthening health systems. As an example, when we look at health systems, such as the ones we have in Uganda, where we have limited human resources, lack of equipment and supplies to even diagnostic supplies, investing in training health care providers, but also alongside that, providing the necessary supplies and equipment would be one way to go about it, but also ensuring equitable access to good quality anti microbials.

Clare Chandler 09:45

One of the things we’ve been trying to draw attention to in our social research is the fact that when we rely on antimicrobials, then how do we ensure that we’ve got good care that goes beyond antimicrobials, and that will be sustainable in the long run, where antimicrobials may be less effective? And similarly, where antimicrobials have come to replace or enable poorer hygiene, we then are faced with a situation where, if the antimicrobials are not available, either because we are seeing resistance to those antimicrobials, or we’re trying to save them, we need to be addressing the things that the antimicrobials are currently fixing for us. So we’ve referred to this as the “quick fix”. Antimicrobials as a stand in for hygiene, or as a stand in for care. We’ve also highlighted, with colleagues, including Laurie Denyer Willis, the idea that antimicrobials can stand in for productivity and inequality, and if you simply say, let’s remove those antimicrobials without identifying the structures that will be needed. For example, sick leave that would enable people, for example, those who work in day wage labor, who rely on antimicrobials, to continue to be able to generate the income that feeds themselves and their families in the absence of effective antimicrobials to do that, or if we try and pull out those antimicrobials from the system because we’re worried about antimicrobial resistance, then we need to ensure that we are replacing the antimicrobials with something else in that structure.

Daniela Corno 11:53

Antibiotics become placeholders for deeper systemic investments, things like better sanitation or fair labor policies that allow people to rest when they’re ill. This perspective helps us see that antimicrobial use and the resistance that can follow is shaped not only by biology, but by the systems people live and work within, and those systems look different depending on the context. In low resource settings like the rural Ugandan health clinic, Dr. Nayiga talked about, gaps in healthcare and gaps in basic infrastructure, like water and sanitation, may drive reliance on antimicrobials and accelerate resistance. Strengthening health systems and access to medicines is critical. In contrast, in well-resourced clinical settings, antimicrobials can also become a default option supported by expectations for quick recovery, time pressured care and cultural norms around prescribing. Here too, antibiotics can substitute for supports like continuity of care, time for patient communication and broader public health measures. Across all contexts, the underlying point is the same. Our reliance on antibiotics reflects the systems around them. Understanding those systems is key to managing antimicrobial use and addressing resistance in sustainable, equitable ways.

Clare Chandler 13:09

And I think when we think about, you know, the infrastructural nature of these substances, the idea that they may not be there in the future either because they are no longer working, or because we fear that they won’t work, and so we kind of pull back on their use. Really requires us to think in terms of, how do we reduce our reliance on these medicines? It also helps us to prompt us to think, you know, how do we channel funding and research and development into new antimicrobials and then into improved diagnostics to tailor our use, but it also the area of how we plan into a future where we’re less reliant on antimicrobials, I think has been less well kind of worked up. So, I think that area of what does a future look like where we are less reliant on them, is different to the idea of going back to the Dark Ages. In the future, we won’t have the anti microbials, and so we are going to go backwards. We can go forwards and say, you know, how are we going to better structure, our architecture of hospitals, our pathways of care, the ways that we kind of invest in hygiene, and the people who do hygiene, the people who do cleaning, how do we change it so that we recognize that these are incredibly important, not the bottom of the pile, because they’re the ones that hold the future of infections in their hands.

Daniela Corno 14:56

That idea of preparing for a future with fewer antimicrobial, not a regression, but a redesign, is a hopeful way to frame this. In low- and middle-income countries, tackling AMR isn’t just a matter of healthcare, it requires investment and cooperation across health, agriculture, water and sanitation, finance and economic development. But this kind of coordination can be easier said than done.

Susan Nayiga 15:22

Coordinated investment across various sectors. So, we are talking health, agriculture, hotel, environment, the finance sector as well comes in, or economic development, whatever that looks like, depending on what country you’re looking at. And I think this is one of the struggles we’ve had like in Uganda, from the conversations in the policy space, how do you bring all these actors to play their part? So, thinking of policy implications also requires that coordination, the integration, to make the best use of the limited resources. But also, I think it’s important to think about the consequences of the solutions that we come up with, and try to address what may be the unintended consequences when we try to come up with solutions to AMR.

Daniela Corno 16:20

So even though there’s acknowledgement that sectors like agriculture, water and health must work together, aligning priorities and budgets remains a hurdle.

Susan Nayiga 16:28

So we find that what happens is whoever brings the money to the table decides what the priority will be for addressing AMR, so you’ll find that some sectors are left out. Certain things become priorities, you’ll find that the focus is on stewardship, and there’s nothing happening with for instance, in the water and environment side of things.

Clare Chandler 16:51

Simply bringing people together across different domains, across One Health, is really important in and of itself. It’s a useful end in itself, but if we’re looking at it as a means to an end of improving and or reducing the burden of antimicrobial resistance across those different domains, we need better, clearer evidence of the impacts of different approaches to do this, and I feel like that we’re still not quite in the place where we’ve got a lot of confidence on the size of relative size of impacts of different interventions for different kinds of settings and I do think that taking an approach when we’ve got a very complex challenge, starting from the size of the impact on the burden that we can see with different kinds of interventions, I think is a sensible approach.

Daniela Corno 17:56

So even when different sectors come together, funding and priorities often shape which interventions get attention, leaving some areas like water and environmental health under resourced. This is why we need a truly integrated One Health approach, which is the idea that the health of people, animals and the environment are all connected. To keep people healthy, we also need healthy animals, clean water, safe food and a well-functioning environment. None of these sectors can tackle AMR on their own.

Dr. Chandler’s point about evidence gaps highlights that coordination alone isn’t enough. We also need data to guide decisions so governments can target interventions where they’ll have the greatest impact. As we look ahead to global efforts like the upcoming revision of the global action plan on AMR, how can this perspective shape real world strategies?

Clare Chandler 18:48

So, seeing that holistic approach, I think, is one of, you know, thinking of antimicrobials as infrastructure is one of the ways of thinking about those entanglements. That means that you know you can’t just take them out of the system and not expect to see some other kinds of impacts. So, as Susan was saying, the idea that anti- microbials themselves are the safety nets, and if you take them away, we need other safety nets in place.

Daniela Corno 19:19

So the lesson seems clear. To reduce resistance, we must redesign the systems that make antimicrobials indispensable in the first place, ensuring people and institutions can stay safe without always turning to medication. Stewardship, in this sense, isn’t just about prescribing less; it’s about rebuilding the foundations that support healthier societies. That was Dr. Clare Chandler and Dr. Susan Nayiga. Thanks for tuning in to another episode of Unpacking AMR. To find more resources about the topic we discussed today, visit our podcast page: https://www.globalstrategylab.org/unpackingamr/

And remember, AMR is more than drugs and bugs.