Re-configuring the concept of vulnerability: Inclusion of refugees in biomedical research

Vulnerable populations in biomedical research have attracted attention in research ethics since the creation of the Nurnberg code in 1947. Research guidelines establish ethical principles in order to protect vulnerable individuals from exploitation in biomedical studies. Vulnerable groups may include women, children, the mentally disabled, racial minorities, or refugees. In this thesis, I will focus in particular on refugees. The uniqueness of refugees can be defined through their сontextuality. Particular, refugees are not just vulnerable individuals who live in the same social, cultural and legal contexts with researchers, but they move from the context of their home country to another context of the host country, thus bringing one context within another. This сontextuality may contribute to additional complexities for the inclusion of refugees to a biomedical study. The thesis consists of five chapters. The first chapter gives an overview of the concept of autonomy and the way this concept has been constructed in medical ethics. I will show how the concept of vulnerability, which indicates certain risks for autonomy, has been shaped in research ethics. The second chapter is devoted to an in-depth analysis of the concept of vulnerability in biomedical research, its rationale, and its limitations. In this chapter, the focus will be on the Belmont Report as one of the most important documents that defines an ethical framework for biomedical studies and gives an explicit definition of vulnerability. The chapter looks through the motivation and reasoning for establishing the concept of vulnerability and provides a critical analysis of its limitations. In the third chapter, I will discuss the concept of vulnerability and its re-definition by three groups of scholars: Hurst (2008), Lange et al. (2013), and Luna (2009). These authors propose context-sensitive understandings of vulnerability that expand beyond its definition in the Belmont Report. I will critically synthesize the three approaches of these authors and emphasize the necessity of looking at the design of biomedical research itself. In this chapter, I will argue for the benefits of participatory methodology. The fourth chapter will give a detailed overview of participatory methodology and of its adaptation in anthropology and learning health system. In the fifth and conclusive chapter, I will analyze what possibilities and limitations participatory methodology can bring to biomedical research involving refugees and propose my own design for conducting such studies

Resistant bacteria in society:Travelling through practices of policy, healthcare and science

Antimicrobial resistance (AMR) is a growing global public health concern that calls for comprehensive transdisciplinary action. Although AMR refers to biological mechanisms of bacterial resistance, it is a deeply social phenomenon that is influenced by economic, political and cultural processes. This research analyses how AMR is incorporated and practised in different settings of policy, healthcare and science and what kind of reality is constructed through these practices. Applying qualitative social science methodology, it shows how current public health practices and policies focus on the opportunities provided by antibiotics. Following this, it demonstrates this focus is too narrow as antibiotics have a limited capacity to prevent infectious diseases. Instead, public health policies should focus on bacteria themselves and their biological mechanisms that determine their boundaries of co-existence with humans. As the global spread of COVID-19 has demonstrated, reliance on technological solutions - such as vaccination or antibiotics - is not sufficient. Pandemic preparedness should be rooted in the prevailing causes of their emergence and spread: poor practices of animal husbandry, increasing market demands for meat, weak healthcare systems and socio-economic inequalities

Combining stool and stories: exploring antimicrobial resistance among a longitudinal cohort of international health students

BACKGROUND: Antimicrobial resistance (AMR) is a global public health concern that requires transdisciplinary and bio-social approaches. Despite the continuous calls for a transdisciplinary understanding of this problem, there is still a lack of such studies. While microbiology generates knowledge about the biomedical nature of bacteria, social science explores various social practices related to the acquisition and spread of these bacteria. However, the two fields remain disconnected in both methodological and conceptual levels. Focusing on the acquisition of multidrug resistance genes, encoding extended-spectrum betalactamases (CTX-M) and carbapenemases (NDM-1) among a travelling population of health students, this article proposes a methodology of ‘stool and stories’ that combines methods of microbiology and sociology, thus proposing a way forward to a collaborative understanding of AMR. METHODS: A longitudinal study with 64 health students travelling to India was conducted in 2017. The study included multiple-choice questionnaires (n = 64); a collection of faecal swabs before travel (T0, n = 45), in the first week in India (T1, n = 44), the second week in India (T2, n = 41); and semi-structured interviews (n = 11). Stool samples were analysed by a targeted metagenomic approach. Data from semi-structured interviews were analysed using the method of thematic analysis. RESULTS: The incidence of ESBL- and carbapenemase resistance genes significantly increased during travel indicating it as a potential risk; for CTX-M from 11% before travel to 78% during travel and for NDM-1 from 2% before travel to 11% during travel. The data from semi-structured interviews showed that participants considered AMR mainly in relation to individual antibiotic use or its presence in a clinical environment but not to travelling. CONCLUSION: The microbiological analysis confirmed previous research showing that international human mobility is a risk factor for AMR acquisition. However, sociological methods demonstrated that travellers understand AMR primarily as a clinical problem and do not connect it to travelling. These findings indicate an important gap in understanding AMR as a bio-social problem raising a question about the potential effectiveness of biologically driven AMR stewardship programs among travellers. Further development of the ‘stool and stories’ approach is important for a transdisciplinary basis of AMR stewardship

From universal frames to collective experimentation?:Pursuing serious conversations about antimicrobial resistance

n the time of coronavirus disease 2019 (COVID-19) there are numerous attempts to compare across national boundaries and rank governments for their action against the virus. In this context the ‘universal’ ambition of the Wellcome Trust report on communicating antimicrobial resistance (AMR) is somewhat refreshing, and recalls some of the older ambition of the global health field. Though the report now feels some time ago – it was published in November 2019 - the pandemic does not mean AMR has gone away. Indeed, it may be worsened in the context of rescue prescribing, both for secondary infections following COVID-19 and other health conditions where antibiotics may stand in for scarce or compromised care. In this open letter we wish to respond to the Trust report – locating it in the field of social science work on AMR – and proposing some directions for further discussion. In particular, writing against the backdrop of the viral pandemic, we explore how both COVID-19 and AMR raise questions about our attachment to modern medicine, about the motivating value appeals to vulnerability and health inequality. We therefore call for the report and others to be the start of the further long-distance conversations and experimentation across different fields

Management of cross-border mobilities during the SARS-CoV-2 pandemic in Europe and implications for public health provision to migrants

While many countries introduced border control measures to prevent the spread of SARS-CoV-2, migrants on the move, like labour migrants and asylum seekers were trapped within the developing border politics. Here, we discuss how pre-existing gaps in international public health infrastructures have positioned migrants at a higher risk of SARS-CoV-2

Antibiotic Use in Pregnancy:A Global Survey on Antibiotic Prescription Practices in Antenatal Care

Antibiotic prescription and use practices in the antenatal care setting varies across countries and populations and has the potential to significantly contribute to the global spread of antibiotic resistance. This study aims to explore how healthcare practitioners make decisions about antibiotic prescriptions for pregnant women and what factors play a role in this process. A cross-sectional exploratory survey consisting of 23 questions, including 4 free-text and 19 multiple-choice questions, was distributed online. Quantitative data were collected through multiple-choice questions and was used to identify the most common infections diagnosed and the type of antibiotics prescribed. Qualitative data were gathered through free-text answers to identify gaps, challenges, and suggestions, and the data were analyzed using thematic analysis. A total of 137 complete surveys mostly from gynecologists/obstetricians from 22 different countries were included in the analysis. Overall, national and international clinical guidelines and hospital guidelines/protocols were the most frequently used sources of information. This study highlights the crucial role of laboratory results and guidelines at different levels and emphasizes region-specific challenges and recommendations. These findings underscore the pressing need for tailored interventions to support antibiotic prescribers in their decision-making practice and to address emerging resistance.</p

The Use of Antibacterial Drugs and Awareness About the Antibiotic Resistance Problem Among the Students of a Medical University

Background. The growth of antibiotic resistance is an urgent problem of modern medicine associated with the irrational use of antibacterial drugs. The solution to this problem requires a comprehensive analysis of the situation not only from the patients' standpoint, but also from that of medical specialists. Aim. To establish the level of awareness about the problem of antibiotic resistance and to study the practice of antibacterial drug use among senior students of a medical university. Material and methods. A one-time sociological study was conducted in the format of an online survey of the 5th-6th yearstudents of the medical and pediatric faculties of the Siberian State Medical University of the Ministry of Health of the Russian Federation. Results. An invitation to the survey was sent to 406 5th-6th year students of the pediatric and medical faculties; 334 students voluntarily completed the questionnaire (return rate - 82.3%). Most students are aware of the problem of antibiotic resistance. 58.8% of the students took drugs as prescribed by a doctor, adhering to the prescribed duration of treatment. The most commonly used antibiotics were: amoxicillin/clavulanic acid - 57.6%, amoxicillin - 29%, azithromycin - 19.4%, ciprofloxacin - 13.4%, 3rd generation cephalosporins - 8.1%. It was found that 45.4% of students used antibiotics parenterally, of which half (50.4%) performed injections at home or in the dormitory. Up to 89.2% of respondents consider it necessary to use medications to restore the intestinal microflora against the background of antibiotic therapy. Conclusions. Despite the high awareness of the problem of antibiotic resistance and adherence to medical recommendations regarding the use of antibiotics, it is necessary to increase the competence in the field of rational antibiotic therapy for both students and practitioners