Workshop 1

Introduction

As the pioneers, AMR social science team arranged the first workshop on AMR Global Challenges and Social Science for two consecutive days on 21st and 22nd Februrary 2019 at Roskilde University, where practitioners and academics on the field of AMR participated. The workshop was part of a four years project that investigates antimicrobial resistance (AMR) through a political science lens, by analyzing the political dynamics that prevent AMR from gaining greater traction on the global policy agenda.

Workshop Summary

The purpose of this summary is to provide workshop participants and other interested parties with an overview of the main discussion points and key statements that emerged from our workshop. Naturally, the summary cannot do justice to the fruitful and detailed discussions we had during our two days. Many thanks to all participants who, unrestrained by disciplinary boundaries and institutional affiliations, contributed to making the workshop a success.

The workshop was held as a start-up event connected to our research project: “Exploring the Policy Dynamics of Global Antimicrobial Resistance Initiatives” (2018-2022) funded by the Independent Research Fund Denmark. The idea was to bring together social science researchers and practitioners working on AMR problems and responses at various levels (e.g. clinical, industrial, national and international) to share experiences and insights. Although this was a brainstorming workshop where debate and discussion took centerstage, we did reach one important decision: the workshop should be repeated in spring 2020. The research team agreed to arrange the second workshop.

The summary is divided up into three major headings synthesizing the three central themes of the workshop: 1) Global challenges of AMR; 2) Is there a role for social science?; and 3) How our particular research project on AMR could proceed.

The list of participants and the agenda can be found here:

Global challenges of AMR

The workshop opened with a discussion of the current state of AMR and the key global challenges that we face when attempting to curb the threat. The debate was spearheaded by three presentations by:

Ute Wolff Sönksen, Medical Specialist in Microbiology, Danish State Serum Institute

Danilo Lo Fo Wong, Programme Manager, Health Emergencies and Communicable Diseases, World Health Organization Europe

Oral presentation only

Jasper Littmann, Director, Norwegian Center for AMR

The presentations and subsequent discussion confirmed that while we know much about the causes of AMR and policies that can effectively combat AMR, efforts are often hampered by a lack of surveillance, regulation and enforcement particularly in low- and middle-income countries. Participants noted that AMR represents a quintessential health system failure that is difficult to address on a global level. The benefits from antibiotic medicine are local but the costs of excessive use are global and mostly born by future generations. AMR can flow discreetly across borders for decades and is often overlooked by most politicians for whom a multitude of more visible and direct challenges take precedence. AMR is also a complex challenge that not only crosses national borders but also sectoral and industrial boundaries. Thus, the consensus was that only very few solutions are fit for universal application. Discouraging inappropriate prescriptions and refining rapid diagnostics, for example, are considered effective policies for curbing AMR but even such solutions need local adaptation. What is applicable to Norway is very likely to be less applicable to Ghana and China. Access to clean drinking water and sanitation might constitute the most effective AMR policy in certain low-income countries. The One Health approach constitutes an important step forward in recognizing that human health is tightly connected to the health of animals and the environment. However, an even more holistic understanding is needed to address the links between human health and country-specific socio-economic and cultural factors.

Many participants pointed to the fact that global attention to AMR appears to be in flux. On one hand, the challenge of AMR has historically suffered from a lack of political attention due to its complexity and disregarded consequences. On the other hand, there has recently been an increased global focus on effective AMR stewardship. Since the World Health Assembly adopted a global action plan in 2015, national governments in 61 countries have now approved national action plans and an additional 87 countries have plans in the pipeline. In 2016, the UN General Assembly convened to discuss AMR for the first time, and the meeting resulted in an AMR declaration signed by 193 countries. That same year, in a rare discussion of health issues at the G20, leaders adopted a communique emphasizing AMR as a serious threat not just to public health but to growth and global economic stability. AMR centers are now opening in several countries. One participant mentioned that ten AMR-centers already exist in Scandinavia alone. The hitherto largest center initiative, the International Centre for Antimicrobial Resistance Solutions set to be established in Copenhagen later this year, only cements this trend.

While this recent attention to AMR should be applauded, it also raises new concerns and coordination challenges. Some participants worried that the attention to AMR has already peaked and that it is now dissipating before any effective and durable policies have been implemented on a global level.  One challenge is that complex and long-term challenges, where political attention has to be sustained and policy solutions span decades, are particularly dependent on a supporting agenda-setting ecology outside the political system, consisting of powerful advocacy networks, strong industrial engagement, continuous public attention, social media interest, and persistent news media coverage. For all its recent setbacks, the global governance of climate change appears to benefit from this supportive agenda-setting ecology – AMR does not yet benefit from such ecology. And, at this stage, it is an open question whether it will develop around AMR.

Another challenge relates to what one participant referred to as “an epidemic of AMR research and initiatives” where research is being conducted and centers are opening without due consideration to existing research and institutional knowledge. New researchers engaging with AMR needs to be very cognizant of their contributions and comparative advantage vis-à-vis already existing studies. From the presentations, it was clear that AMR can be approached from a multitude of perspectives. AMR can be approached as medical problem, a security problem, a collective action problem, a sustainable development problem and so on. Each of these framings carry with them distinct disciplinary and methodological approaches. Research into AMR needs to be specific with regards the perspective that is primarily being applied. A few participants cautioned against focusing too much on human health while overlooking the veterinarian dimension. In addition, this recent increase in attention to AMR could be counterproductive if new evidence, alternative questions and interdisciplinary perspectives substitute for policy action. One participant cautioned against being lulled to sleep by all these new initiatives, so that we end-up ignoring the need for political action both nationally and internationally. 

The discussion proceeded to address the question of framing. The question of framing and political attention carried direct relevance for the next overarching item on the agenda: what can social science contribute with?

Is there a role for social science?

The purpose of next major session was to carve out a role for social science and to pinpoint concrete research ambitions that this type of research should have. The discussion was initiated by five presentations by:

Jeremy Shiffman, Professor, Johns Hopkins Bloomberg School of Public Health

Arjen Boin, Professor, Institute of Political Science, Leiden University

Oral presentation only

Carsten Strøby Jensen, Associate Professor, Department of Sociology, University of Copenhagen

Erik Bækkeskov, Senior Lecturer, School of Social and Political Sciences, University of Melbourne.

Jon Pierre, Professor, Department of Political Science, University of Gothenburg

Not surprisingly, the short answer to the initial question was: “yes – social science can contribute with something.” However, there was disagreement on what that “something” should be. Should the social science research primarily be applied, and by extension investigate themes pointed out by practitioners? Or should it primarily pursue a basic research agenda with the purpose of expanding knowledge (theoretically or methodologically) within the disciple? Some participants encouraged us to follow the applied perspective: “we have to stop admiring the problem of AMR, but we need to act on it.” Other participants emphasized the importance of basic research, and posited that the interesting perspectives rarely emerge from practitioners. This issue remained unsolved, and a division could be identified among the participants. While it is tempting to claim that social science research can inform both agendas, there is a core distinction between applied and basic research that remains insurmountable. This, of course, does not mean that basic research cannot be of value for practitioners; neither does it imply that applied research cannot contribute to moving a discipline forward. But it matters for the research thematic choices and scientific aims, and it was something we would need to consider on the second day (see “How should this project proceed?”). 

There was consensus that social science theories, such as agenda-setting theory and policy network theory, carry much potential for AMR research. There was also general agreement that there is significant room for describing and explaining how different levels of governance are responding to the AMR challenges. As part of this discussion, we broke into four smaller interdisciplinary groups to identify key global challenges. The resulting posters can be observed below.

A few challenges appeared to cut across posters. Collective action problems and tragedy of the commons were both identified impediments to effective global governance.  Issues of framing and complexity were also emphasized as having consequences for the stewardship of AMR. The discussion of these posters also engaged with the resilience debate: is the challenge of AMR so context-specific that global governance initiatives should be abandon in favor of national/local systems that are more adaptable when dealing with this type of wicked problem. If there are no universal solutions to AMR, then perhaps we should (also) aim for improving resilience to AMR to better absorb the adverse consequences?

How should our particular research project proceed?

The second day was devoted to discussing the project’s specific research design. The format was thus geared towards more targeted inputs of possible research designs and theoretical approaches.

Postdoc Louise Munkholm presented our research project:

There was consensus among the participants that our research endeavors going forward should include a greater diversity of theoretical approaches and analytical themes. Our original research proposal relied on a specific theoretical approach, namely Kingdon’s Multiple Streams Approach (MSA), and set out to investigate the timing and content of global AMR initiatives through a comparison with past climate change initiatives. Theoretically, some participants argued that MSA might have problems capturing variation over time as well as supranational dynamics. In fact, less than one percent of MSA studies do address supranational dynamics as the main focus of the study. Aside from the potential internal validity problems with the MSA approach, most participants argued convincingly that the research project would benefit from addressing multiple but interrelated themes; accordingly, we would need to draw on several theoretical perspectives from a broader pallet of agenda-setting theories and beyond. Thus, it was suggested that we downplay our comparison with climate change initiatives in favor of a more diverse range of interconnected sub-projects all addressing the common theme of global policy dynamics of AMR. Our research strategy should then pursue smaller research papers or briefs based on individual ideas and novel perspectives within the overarching theme of global policy dynamics of AMR. Over the four-year project period, this would also provide the necessary flexibility and adaptability to capture new thematic opportunities likely to emerge in the vibrant research and policy field of AMR. This more diversified research strategy was elegantly articulated by one participant: “Split up the team, you are four people!”

Participants advised us that AMR should be a case of something and one unifying theme that did appear to emerge from the workshop was the concept of creeping (transboundary) crisis.  More concretely, we could study how AMR moves from being primarily perceived as a technical long-term problem of secondary importance (the ‘creeping’ part) to suddenly erupting into being perceived as an emergency worth of immediate international action (the ‘crisis’ part). Here punctuated equilibrium theory would be obvious to draw on. A related field of inquiry would be how attention is translated into policy. It is unclear whether the current upsurge of global attention actual translates into effective global policies to curb AMR. As previously reported, some participants feared that the attention is already abating, and the window of opportunity is closing. Creeping crises are especially exposed to moving in and out of the global agenda, and the implications for policy-making could be the subject of further research.

Our global governance research focus would be able address many different dimensions of AMR governance, each within a well-established theoretical framework. We could analyze the challenge of global AMR governance as a collective action problem; we could focus on norm life cycles/policy diffusion to account for the spread of AMR attention and policies across borders; we could investigate the dynamics and characteristics of the global health network surrounding AMR; we could engage in subnational analyses of global solutions through polycentric governance theory; and we could draw on sociology of law in comparing global AMR initiatives with other international guidelines or even treaties, including how they are developed and enforced. Data collection and methodological design would depend on the specific research question. In most cases, we plan to rely on a mixed method strategy (nested approach) where a quantitative analysis is used as an initial step towards a qualitative analysis or vice-versa. The Tripartite Plus (WHO, OIE, FAO and UNEP) would obviously constitute an important source of information. Political ethnography or simply interviews/focus group discussions would need to be undertaken in one or several of these agencies. Other research questions might be better suited for a comparative research design by comparing a smaller subset of countries or agencies. 

An interesting global trend that could also be subject to analysis is the concrete capacity building initiatives that are currently being implementing in many countries. The National Action Plans are one manifestation of capacity building. Another relates to the many new AMR centers that are currently operational. Although the trend is global, our research design would be based on comparative politics where we contrast these different centers: how they came into being, their biographies, their mission statements, agendas and research projects, funding structure and extent of cooperation with other agencies. Participants suggested that researching these recently established centers could illuminate the tension between the national and the international (or the physical and the virtual) on a more theoretical level as well as having some concrete applied value: what makes an AMR center effective? How do we avoid replicating what is already out there?

Next steps

Within the next few months, the team will develop a four-year research plan and a preliminary portfolio of work packages. All information will be posted on our website. We plan to reach out to relevant partners for potential research collaborations as well as reach out to important practitioners/experts to gain access and insights into key developments and processes. All participants cordially agreed to help facilitate contact to relevant AMR-stakeholders.

Roskilde University, Tuesday, March 26, 2019

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