[MUSIC] Hi, my name is Steven Hinchliffe and I'm going to be talking about the Geographies of AMR. In this presentation I'll introduce you to some key geographical features of the AMR problem. Our top three areas. First of all the drivers of antimicrobial resistance. Secondly, the mobility's of the resistance that are generated and then a kind of so what. So what do we do about these kinds of issues and how do we approach them by tailoring our policy to specific context? So let me start with the drivers of AMR. Of course as we know, is a global problem. But the drivers that caused the emergence of resistant organisms and allow them to persist and then be transmitted need to be understood within specific situations and locations. They are in my language spatial. They're dependent on local and non local and a kind of network of local and non local drivers. Antibiotic use is for example, the excessive use of antibiotics, antifungal and so on. Often relate to the burden of disease, which of course is variable that may itself be dependent on. For example, poverty conditions, inequalities, the stress of climate related impacts on organisms and environments and so on. It may relate to the lack of alternatives. We know that uses of antibiotics are often related to or they mask the insufficiencies in healthcare. If you can't get any other kind of treatment for your illness, then the pill is a kind of magic bullet. And that happens in livestock and veterinary settings as well where farmers often mask poor livestock husbandry with the use of antimicrobials. But they also relate to broader issues of economics, culture and history. And just one example, we could look at this bar chart on the left shows the variation in community use of antibiotics within the European union, the European economic area. And you can see there's a wide variety and I just want to focus on Spain, which is actually worse than that bar chart suggests. Because this only includes community prescriptions, not the over the counter sales, which is still possible in Spain at the time that this was made. So why Spain got such a high value? because Spain is one of the highest users. And in order to understand that we need to turn to history and culture. In fact, in Spain after the Civil War in the 1930s, the production and delivery of penicillin to the Spanish population became part of the national strategy to rebuild public health. At a time when there was little infrastructure and healthcare left after a war, when there was of course a lot of illness and injuries to treat, the free or widespread availability of antibiotics became part of the culture of healthcare activities within Spain. And that starts to explain some of the reasons why you have high uses in that particular environment. And to understand that to address the problem, you need to understand that broad cultural sense of why antibiotics are freely available. We can also talk about similar issues when we consider the persistence of resistance within environment and its transmission between people and between animals and people. Now in order to persist we need to maintain selection pressures. Those are the pressures that ensure that the resistant strains can compete against other strains within the environment. And often that's about continuing the use of antibiotics, but also other factors like the local soil conditions, the water conditions, the mix of antimicrobials in the environment, something we could call the pathobiome more the mix of microbiological organisms and the environments that make a micro bio community more or less likely to form and sustain resistant communities. Transmission is similarly multifactorial. The ability for transfer of pathogenic and commence cell strains, the latter of which might not make you will but nonetheless they carry the resistant genes if you like, which can be passed on to pathogenic organisms once you get infected and cause a problem. And all of those will be affected by what's the status of water, sanitation and hygiene in the local area. Whether there are livestock practices that mean people and animals mixed on a regular basis, but also cultural norms. And just to take an example here work with the Maasai nomadic pastoralists in Tanzania has focused on the rise of the use of antibiotics in cattle itself, often related to climate stresses and so on as the cattle become increasingly stressed by arid periods and so on. But possibly just as significantly, it also focuses on the need to reduce transmission of bacteria from cattle to people. But most of that transmission occurs when people drink the milk from their cows, of course not pasteurized. So a key issue here is how to encourage the the Maasai to pasteurize their milk. They're often resistance to it because that in the past has usually been they've been advised to boil the milk which changes the milk texture and taste and no one wants to do that. So what the researchers and colleagues have come up with our robust thermometers that can be read in the dark and used as an indicator of just enough heat treatment to reduce the activity of the bacteria. So it's not passing on resistant traits but it's not to warm if you like. It's around 70° so it doesn't affect the taste and texture of the milk. So again, understanding these local cultural and environmental pressures allow someone to come up with a workable and sustainable solution. Transmission of course is not just a local issue. Resistance can be mobile across the planet and of course there's travel international travel, trade and transport move resistance from community to community and across environments. Sometimes with startling speed baker and colleagues have mapped in this infographic map the spread of three resistant strains of common bacteria in these kinds of ways over several years. But as I said, the process can be incredibly quick. And one of the issues that raise this attention, not just the recent pandemic where we know of course microbes can move around the world with astonishing speed, very predictable, but also the example of the identifying the resistant gene for colistin, for example, in livestock in China. When we started looking, we realized that that was already globally widespread, which may have happened in quite a short time periods. The implications should be obvious after we've lived through the current pandemic is that while AMR threats may emerge in specific locations, the potential effects are global. So the final points that I want to make then, I think the key point from today from this session is that the drivers of resistance of course are spatially heterogeneous, their local and they relate to the kind of the folding together of various kinds of drivers together in specific constellations that are locally specific. This is partially recognized in the the recent World Health Organization tailoring of antimicrobial resistant programs or tap toolbox, but that focuses very much on clinical and behavioral interventions within local environments. And what I'm talking about a much broader set of issues that relate to drinking milk to livestock care, all kinds of environmental issues and so on. So let me take a final example to illustrate what I mean. Here in an example in in aquaculture in Bangladesh or the farming of fish and other aqua livestock, which has been vital for the development of Bangladesh. It's food and economic sufficiency. Farmers in Bangladesh tend to operate their ponds by stocking quite frequently with a mix of species often. And even though there's a high disease burden, they do that in order to make sure they're generating a a serviceable crop and making some money from their enterprise. But one of the biggest users of the disease burden and the increasing use of treatments to deal with that disease burden. So one policy has been to adopt what are called disease free approaches. And this is where farmers were encouraged to stock disease free seed that was grown in hatcheries tested and so on. That didn't have some of the kind of common production diseases. But while they were doing it, the farmers were also told just stock once, don't stop frequently, just use our better seed and you will have an improved harvest with less disease and so on, which sounded entirely sensible. However, when we looked at this in more detail, we found that when the farmers put all their eggs in one basket or stocked once they were actually increasing their exposure to not more disease, there was less disease in the system. But if they did get disease and it's impossible to completely eradicate, there's no such thing as disease free farming. Once they did get disease, they were more likely to treat their produce because all of their stock was in one segment they didn't have different species and so on, which would reduce the effect of that disease. So paradoxically, we argue that disease free farming was increasing the exposure of the farmers to risk. And even though disease was going down, it made medicine use more rather than less likely because the farmers felt less in control, they couldn't top up their ponds and so on. So particularly in a physically and economically variable climate where monsoons can fail, where prices can go up and down. The previous method of farmers stocking frequently was actually a more sustainable and less likely to use excessive treatments than the alternative. So the solution to this is to work with farmers to tailor policies and programs. In order to do that you need to engage with key actors forming what we call competency groups to develop key levers for change. So for example, in this case we worked with scientists, farmers, various people from the industry to understand the entire production system. It's physical and economic risks in order to tailor or adapt programs. And you can do this for poultry in some of the pictures here as well as for aquaculture. In this case, the challenge was the role of pharmaceutical companies in encouraging greater use of antimicrobials. So farmers talk to us about that. So we explored this or are we are exploring it by mapping social networks along which information goods and resources flow in order to understand the power relations that are producing more pressure to use antimicrobials in these environments. We also highlighted the difficulties farmers have in maintaining water quality which can of course affect their health and the disease within their system and the role of microfinance in shaping farmer practices. The point is you need to understand these factors if you're going to really generate sustainable and sufficient change. So the key learning points from today are first resistance, it's evolution, persistence and transmission is generated by many factors. It's not just use and we need geographers and more geographers to be able to map the key drivers and understand any emerging levers for change is to take diagrams like this on the right, which are very useful at summarizing some of the key drivers of resistance and to start to put the detail on those in specific low context. So we can understand what it is about the animals in the left of that picture to understand the farmers, the markets, all the kinds of things that are driving treatments in order that we can come up with sustainable solutions, it's the local and nonlocal drivers that we need to understand. And once we understand some of the social economic as well as physical and biological mechanisms of AMR. We can make sure that policies programs are locally sensible, They meet cultural economic and environmental conditions and therefore have the chance of being more effective. Okay, I would like to thank you and thank, of course, the team at Sona Global. And I wish you all success with your records. Yeah.
