“We Want to Prevent Resistance”: Shopkeeper Stewardship Anticipating Antimicrobial Resistant Pathogens in Accra, Ghana

Author’s Note

What was your thesis topic?

The project studied the distribution of antibiotic and antimalarial medications in pharmacies and chemical shops of Accra, Ghana, looking for patterns in how these medications are distributed. This study sought to find patterns in community-level health care and predict the emergence of antimicrobial-resistant pathogens. The survey questionnaire investigated the ways in which antimicrobial medications are distributed at the community level, whether there appears to be a great deal of misuse of medications, how stewardship and insufficient funds are navigated, and how these connect with the socioeconomic characteristics of the neighborhood surrounding each shop.

What do you think the stronger and weaker parts of your research are?

Strengths: The survey administration went extremely well, including 83 field site locations all throughout the city of Accra and going in-depth with each one. Each survey took 30-90 minutes to complete, involving a high level of detail in responses in a way that doesn’t appear to have been done before for this context. 94% of the field site shops we entered agreed to participate, which is almost unheard-of in survey research. There is a huge volume of data, and the questions were asked with sufficient consistency that the findings can be trusted.

Weaker parts: As a white US American, I can never fully understand the nuances and complexities of shopkeepers’ or medication users’ lives in the place I conducted this research. I worried about perpetuating colonial hierarchies while conducting fieldwork in Ghana. There has been a great deal of damage done by academia and researchers through the imperial attitudes that have been intrinsically part of how research is often conducted by outsiders like me. Thus, the risk of misinterpreting or misrepresenting this context could be a serious weakness. Additionally, and partially a result of the research’s strengths, there is so much data accumulated that it’s hard to know whether I’ve done it justice by trying every possible combination of variables or finding all of what are the most important takeaways.

In what ways do you think your topic improves the world?

Antimicrobial resistance is considered one of the biggest impending public health catastrophes of the century, and it is critical to understand where and how antimicrobials are used, in order to slow the spread of AMR. This project illuminates trends that can help pinpoint where antimicrobial resistance is most likely to emerge and enable targeted, focused, effective interventions to act preemptively. This survey questionnaire turned out to be extremely successful with questions to illuminate points driving risk, and the survey can be reused and replicated worldwide. AMR is a global issue but is most likely to devastate the communities least prepared to mitigate such outbreaks; yet research has typically been concentrated in hospitals in wealthy countries. This project starts to correct that, by showing how the risk of AMR manifests distinctly in each context worldwide. The findings show that shopkeepers are incredibly important agents of community-level public health, and hopefully this helps amplify their voices and ensure that they are valued for the agency and awareness they hold.

This argument could be strengthened by considering that the last few centuries have seen humanity’s power increase immensely, and we may one day be able to mould the very atoms of the universe into whatever we choose. We might also hand off most of our decision making to autonomous systems. Either way, making our decision about how to use our cosmic endowment wiser, and improving the values we ultimately align our decision-making systems with (hopefully we can align them), will be extremely valuable, much more valuable than previous work seems to us now. My work, then, could be seen as a tiny unit of progress that contributes to this broader contribution of value.

In what ways have you changed your mind since writing it?

I had heard from prior researchers that medicine shopkeepers often throw antibiotic medications at every symptom, even when they are not at all likely to help. In reality, I found that shopkeepers do practice stewardship of these medications and have a high level of knowledge, along with a great deal of awareness and agency.

I discovered how the majority of health-seeking and health care seems to happen outside of hospitals and doctors’ offices. The importance of community-level pharmacists and medical shopkeepers in Accra showed how access to hospitals and doctors is a privilege, illuminating how the majority of the world isn’t given access to healthcare in formal institutions.

I’d spent years planning to become a physician, but now I’m questioning whether that is the most impactful career based on how much of the global population is left out of hospitals and doctors’ offices.

What recommendations would you make to others interested in taking a similar direction with their research?

Reflect early and often on the history of research fieldwork in the place you are conducting it, and how your identity (especially if it is one of privilege) can uphold problematic histories. I conducted my research during a study-abroad semester in a place where public health researchers were agents of violent colonial expansion, and I look like them. Thus the act of doing fieldwork is sometimes ethically murky, especially if it has the risk of perpetuating history. There is a lot of internalized imperialism in research, but it’s typically not addressed in the text of an academic publication. So be wary of how you present the research, especially if it can be interpreted in ways that undermine the agency or autonomy of interlocutor populations.

Do fieldwork if possible. There is something incredibly valuable about learning to interact with individuals in a way that goes beyond laboratories when fieldwork is done intentionally in a way that tries to dismantle the typical subject vs. researcher divide.