Internet regulation

As noted, a concern for researchers has been the easy discoverability of unregulated pharmacy. Internet search providers are routinely criticised in the UK, USA and Europe (Boyd et al. 2017; LegitScript 2016; Liang and MacKey 2009; Mainous et al. 2009; Orizio et al. 2010) for enabling unregulated pharmacies to promote themselves using typical publishing tactics. Web pages can be crafted for search indexing (often called search engine optimisation or SEO) and written to match as many user queries as possible. Unfortunately, the evidence base for these practices is ever-shifting, with constant updates to search algorithms, and in-kind responses from pharmacy operators. Google (along with other technology companies) have publicly expressed support for The Centre for Safe Internet Pharmacies. Microsoft (see Bing 2021)—whose Bing search engine also powers Yahoo!—and Google (see Google 2021; Underwood 2015) publicly state the quality controls they employ on health-related searches.

Despite these measures, our Google searches delivered many specific results where—among a patchwork of other consumer goods—news media, and advertisements, antibiotics could be purchased. These include the unregulated websites that dominate extant literature, as well as animal products and direct links to antibiotics on regulated domestic chain pharmacies. In many cases, products from chain stores appeared at the top of search listings as paid advertisements. We note, however, that in comparison to less algorithmic search providers (DuckDuckGo), Google results had fewer unregulated pharmacies, and included news results about antibiotics in human and animal contexts.

Pharmacy sites surfaced in our search used a range of consumer-facing, quasi-regulatory strategies, as documented elsewhere (Mavlanova and Benbunan-Fich 2010). These strategies included visual indicators (seals, badges and icons) to assert legitimate pharmacy operations in a given jurisdiction. Some stalwarts here include the US-based ‘Verified Internet Pharmacy Practice Sites’ (VIPPS) (Liang and Mackey 2012)—now known as the National Association of Boards of Pharmacy (NAPB) accreditation—and the international ‘Health on the Net’ (HON), which acts as both a code of practice and a visual seal of accreditation (Qin et al. 2021). These two examples harken from the late 1990s, and while recognisable, their iconography appears dated and illegible by modern standards. A more consistent contemporary application of this type of visual indicator is the UK‘s ‘Distance Selling Logo’, governed by the Medicines and Healthcare products Regulatory Agency. This logo appeared with regularity on UK and European Union (EU) pharmacies cleared to dispense within/into the UK via post.

In the Australian context, the websites of regulated domestic pharmacy chains often used plain-text footnotes to convey official licensing information, and some used logos and seals to indicate Quality Care Pharmacy Program (QCPP) certification (analogous to the use of VIPPS/NAPB/HON earlier). As in other jurisdictions, Australian accreditation occurs through self-regulating bodies that, when explored, quickly devolve into dense explanations likely to alienate consumers. Importantly, this accreditation seems at odds with the robust systems that govern practitioner and prescribing practices, such as those employed by the Australian Health Practitioner Regulation Agency (AHPRA). Unlike AHPRA, QCPP information is inward-looking: oriented towards the minutiae of accreditation rather than medical information and consumer safety.

Without widespread or universal iconography, verifications present an informational barrier for consumers. If unfamiliar with a particular certification system, consumers need to click-through multiple webpages to understand the source of accreditation. Consumers evidently ignore verification iconography—given the global unregulated exchange of human and animal antibiotics (Boyd et al. 2017; Howes-Mischel 2017)—and research that indicates more time is spent reading descriptive text when browsing pharmacies (Qin et al. 2021). Other visual ‘trust features’ (Mavlanova and Benbunan-Fich 2010) that are not pharmacy-specific are common to both regulated and unregulated vendors. Notably, the use of payment providers’ logos and internet security verifications are almost identical. This includes payment logos (VISA, American Express) and security imagery (locks, keys, shields), which are displayed to achieve similar affective qualities, including familiarity, certification, legitimacy and security. Online pharmacies (both regulated and unregulated) arguably deploy forms of iconography or branding to perform trustworthiness to a generic consumer, asking them to assess whether the website is valid or authentic.

Pharmacy design

Befitting the ‘late capitalist’ pastiche, online pharmacies (regulated or otherwise) transform pharmaceutical healthcare, enabling prescription medications to be co-located with health products that do not require prescription. We find they allow consumers to essentially ‘window shop’ prescription medications otherwise secured ‘behind-the-counter’. In many jurisdictions (including Australia), there are restrictions on DTC advertising for prescription medication, yet online marketplaces allow products to be browsed and searched (Hope, Mayne, and King 2015), while also displaying cost estimates for both private prescriptions and government subsidies. This inverts standard treatment pathways, whereby consumers encounter medical advice prior to seeking a specific medication or knowing its cost. Even website structures and layout—collective categories like ‘antibiotics’—subvert AMR prevention: broad categorisations undercut strategies which seek less and more accurate use of antibiotics. Again, it is particularly concerning for AMR, that we saw broad-spectrum antibiotics (like amoxicillin) prevalent in our online ethnography (as elsewhere: Boyd et al. 2017; Howes-Mischel 2017; Reddy et al. 2021; Venhuis et al. 2016).

We also found that the antibiotics market follows other drugs, particularly those already examined in previous online pharmacy research. In addition to antibiotics, we found ‘antivirals’ and ‘HIV’, ‘weight loss’ (presented as top-level categories on unregulated pharmacy sites), and various bulk purchasing options for tadalafil (Cialis) and sildenafil (Viagra) listed as erectile dysfunction ‘ED packs’. These observations complement do-it-yourself approaches to HIV treatment (Davis and Flowers 2014), as well as continue to support the foundational findings of e-pharmacy research on sildenafil (Armstrong, Schwartz, and Asch 1999; Eysenbach 1999): including the way sildenafil permits normative understandings of health and bodily function to be maintained through diverse practices of consumption (Potts 2004). The browsability of antibiotics in a context of radical consumer choice, sees them follow other medicines in becoming ‘commodities’ (van der Geest and Whyte 1989, 350). Online, the widespread availability and low cost of antimicrobials paves pathways to alternative means of procurement, self-medication and polypharmacy (see Brijnath 2012).

Freed from brick-and-mortar pharmacy structures, online consumer pathways exist within personal, local and global contexts. Just as we did in our search process, consumers can navigate search engines, pharmacy sites and sources of user-shared information within the ‘the digital patient experience economy’ (Lupton 2014): a space supposedly comprised of, and designed for, ‘digitally engaged patients’ (Lupton 2018; Petersen 2019). Well-versed in ‘savvy’ consumption, these users are able to understand medical information, and balance their health and financial needs . Websites we explored used this kind of language, championing their own ‘reliable information’ and ‘cheap but effective’ goods, and calling on consumers to ‘stop wasting time’ and to ‘forget about the old way’.

However, not all consumers match this empowered archetype (Brijnath 2012, 297; 304), and they likely bring health inequalities to bear on their consumption practices (Fox and Ward 2006). Increasingly, too, patient/consumer agency is augmented and shaped by the personalised, algorithmic, and non-linear online environment. Internet sites compete for user attention, drawing on extensive data histories generated by searching, shopping and consuming media. The algorithms used to personalise search results remain opaque, and consumer controls for filtering results are limited. This was readily apparent during our research process, and is ultimately what necessitated a comparison between two researchers’ search results. Search companies are willing to apply some quality controls to health-related content (Google 2021; Underwood 2015), but not—it appears—at the expense of personalised and advertising-driven search results.

In this competitive search-driven environment, pharmacies are also highly commercialised. Regulated and unregulated sites adhere to visual tropes of e-commerce such as large banners to promote discounts and special offers. The only distinction is that regulated pharmacies can sell these banners as advertising space. Regulated sites feature recognisable products, while unregulated sites offer a pastiche of this: imitating the basic elements of branded promotion without the branding. Evidence suggests that this kind of presentation downplays the seriousness of medicine scheduling and prescribing: matters of availability, storage, and advice regarding dosage and side effects are given less attention than the consumer conveniences associated with online shopping (Orizio et al. 2011). In emphasising a commercial approach to medicine, both unregulated and regulated online pharmacies distance consumers from gatekeepers and healthcare conversations, reducing the figure of the pharmacist, for example, to stock images of white-coated, clipboard-holding individuals (see GlobalData Healthcare 2018 for an example of this imagery). Consumers, however, may view these marketing tropes as a sign of legitimacy and regard familiar products as safe and efficacious. In both typical and pastiche forms, these familiar commercial pharmacy motifs are harnessed to promote the quality, safety and value of medicines on offer.

While issues of drug provenance and safety are more immediate in unregulated spaces, chain pharmacies generate their own unique forms of confusion. Online arms of chain pharmacy operations offer large stock lists of medicinal and non-medicinal goods (including vitamins, skincare and perfumes). The breadth of product categories visible to consumers in such spaces only amplifies messiness: our pharmacy search results included tangential products surfaced by their linguistic similarity to ‘antibiotics’, such as probiotics and antibacterial soap. Moreover, consumer pathways with large chains are not always kept in-house. Many large pharmacies also use third-party sites, such eBay, to advertise and process their online sales (Hope, Mayne, and King 2015). These results suggest there are gaps in the oversight of pharmacy communications, undermining Australia’s tight controls on DTC marketing, and eroding the distinctions between global unregulated marketplaces and the controlled domestic health systems. This is significant when, as recently as 2019, Australian pharmacy sites were found to be illegally advertising goods that had been cancelled from the Australian Register of Therapeutic Goods (the register that governs what products can be legally supplied to Australian consumers) (Therapeutic Goods Administration 2021). The presentation of antibiotics in context of general slippage in regulation further undercuts AMR prevention.

Information provision

Regulated online pharmacies usually provide little-to-no information about medication purposes, doses and side effects. This absence might be due to an assumption that such information is the domain of manufacturers, regulatory and administrative bodies, and GP or pharmacy prescribers. In contrast, and despite often not employing qualified pharmacists, unregulated pharmacies provide extensive information. Every medication promoted has extensive and uncited explanatory detail, with further general information at the category levels within sites (ie, ‘antibiotics’). One site we found presented over 500 words of descriptive text about amoxicillin, including uses, directions, contraindications, effects and side effects, and drug interactions. This information was not attributed to a manufacturer, government regulator, qualified dispenser or healthcare provider.

Across unregulated pharmacies, information varies greatly in style and intent. Some texts are coherent, while some are jumbled (both semantically and semiotically). Texts sometimes feature tangents about the history of medicine or random clinical research findings. The authorial voice also varies between sites and site areas. In some cases, the shopfront conveys information (for example in FAQs), while in others, the voices of the (alleged) consumers speak through reviews and testimonials. It is unclear whether these texts are written, translated or assembled algorithmically from health-adjacent sources—or some combination of these possibilities. Moreover, the purpose is unclear. Pharmacies may seek to convince consumers using (seemingly random but real) evidence from scientific orthodoxy (see van der Geest and Whyte 1989; Langford 1999); conjure (or at least permit) alternate imaginaries of the self as consequence of medicine consumption (see Martin 2006); extend the metaphors (ranging from fantastical ‘monsters’ and ‘magic’ to the more banal ‘illness journey’) already present in manufacturer advertising (Delbaere 2013); and/or maximise search visibility through an excess of health-related language (the ‘SEO’ referred to earlier). Despite suggestions that the number of individual ‘rogue’ merchants is decreasing in favour of cartels (LegitScript 2016; Mackey and Nayyar 2016), our initial attempts to search and reverse-search for text and images (ie, of boxes and medicine blister packaging; distinctive text phrasing) did not reveal commonalities nor any systematic approach to the creation of this content.

Unregulated pharmacies are open to all-comers regardless of their e-health literacy. The information they share is especially dangerous when targeted towards specific populations, on vectors of rationality and emotion. We found several pharmacy stores engaged in practices of ‘cybersquatting’: either purchasing lapsed web domains (the whole website), or by exploiting security vulnerabilities to insert an unregulated pharmacy within an existing site (hiding an additional webpage within the broader website). Crucially, these cases appeared at websites that already hosted targeted health content. Examples included a hospital, chiropractor and a site about medication subsidies for social welfare recipients. From the perspective of search indexing, these sites are already associated with health-related language. Cybersquatters therefore leverage existing site SEO and search rankings to reach and exploit specific groups. Unregulated pharmacies, then, are not merely free-market opportunists or ‘spam’ tacticians (Brijnath 2012, 294) but may be conscious of how researchers or regulators might attempt to interrogate their operations. One site prevented us from right-clicking (an action that might allow copying of text or exploration of a site’s code) by issuing a pop-up warning ‘fuck off!!!’.

Unsurprisingly, the extant literature expresses concern and worry about ‘rogue’ pharmacy operations. However, we see unregulated pharmacy as a more polarised phenomenon: invaluable for some stigmatised communities (Davis and Flowers 2014), yet harmful to other marginalised consumers. We see AMR as a particular problem for the latter, given the evidence of misleading claims regarding the efficacy of antibiotics for some conditions (Reddy et al. 2021), antibiotic stockpiling as an expression of system failure (Howes-Mischel 2017), and the threat of resistance itself: localised antibiotic misuse by individuals or groups has ramifications at a societal level. Again however, ethnographic, cultural and networked approaches are a significant gap in current AMR prevention (Tompson, Manderson, and Chandler 2021 4-5; Hansson and Brenthel 2022).

In addition, we found, as others have (see Brijnath 2012; Brown 2018; Brown and Nettleton 2018), that AMR is implicated in the politics of nation states, borders and migration. In the same way the DTC drug marketing crosses borders (Delbaere 2013), unregulated sites openly play with the globalisation of pharmacy. Despite protections that are imposed on domains—for example, Australia’s ‘.com.au’ is closely administered by the .au Domain Administration Foundation—sites can simply include nations in their domain names: a web address can contain the word ‘Australia’ even when using an international domain with less stringent governance. Australia’s official tourism website ‘australia.com’ provides an example of this practice. In a key difference to earlier research (LegitScript 2016), we experienced first-hand the waning utility of the WHOIS database under the Europe’s General Data Protection Regulation (GDPR) (see Lu et al. 2021). The GDPR is EU legislation, designed to enhance user privacy. But pharmacy sites are also ‘users’ of web domains, and use these affordances to obscure their identity. In our research, we found the true location of pharmacy stores (or at least their registration location) was not hidden, and likely blocked at the request of vendors. For a health consumer, this lack of transparency further obfuscates how medicines might be sourced and dispensed, shapes interactions with pharmacists (if any), and may alter local importation and biosecurity requirements.

The visual signifiers discussed earlier are also used to pastiche geography: seeking to engage global audiences via the use of national flags, currencies and international shipping options. We found Canada-related iconography particularly prominent, used to signify a reliable, affordable and safe pharmaceutical market. This is particularly resonant with US consumers, but relevant globally (see Delbaere 2013). Brijnath (2012) and Venhuis et al. (2016) both consider how unregulated vendors might attempt to activate specific diaspora communities by promoting medicines based on cultural beliefs, or value assigned to the country of manufacture. However, this is harder to discern regarding antibiotics: they are misunderstood and misused but are not themselves ‘alternative’ medicines. Regardless, their transnational availability online is undoubtedly an expression of how AMR is produced at the intersections of medicine, global markets, nations states and border politics, as well as the kinds of individual meanings attached to generic imported medicines seen in existing e-pharmacy research (Fox and Ward 2006, 469). This is yet another wrinkle in the ‘patient experience economy’ (Lupton 2014) in which consumers’ experiences are mediated by their personal biography, vendor tactics, and ability to parse and filter information.

Regulation and markets

A key finding is that the regulated/unregulated mix of e-pharmacies has a paradoxical effect in service of consumers. The legitimate online pharmacy sector does seemingly little to engage consumers, assuming that their services are part of orthodox healthcare and the advice provided to patients therein. In contrast, unregulated e-pharmacies provide consumers with copious information of dubious soundness. The overall impact of this pattern of absence and overcompensation is to amplify poorly communicated advice that may compromise efforts to reduce the use of antimicrobials. In addition, some codes of practice (for internet companies, digital retailers or pharmacists) may be in place, but are often enforced by private accrediting agencies operating in consultation with the sector(s). Internet regulation—especially in the burgeoning prosumer-driven health data economy (Lupton 2014)—presents a particular impasse, running counter to profit motives. Site traffic generates revenue through hosting, searching, sharing and advertising. The workings of such processes are equally opaque: ‘black-boxed’, prized and protected by corporate interests. Such tensions—between opaque ‘more is more’ and transparent ‘less is more’ approaches to consumption—are amplified in connection with AMR prevention: it is restricted availability and prudent use that keeps antibiotics safe. In keeping with a holistic ‘One Health’ approach, we see these issues as extending beyond primary healthcare, with dispersed responsibility in areas of consumer medicines information provision, pharmacy governance, retail trade and internet content moderation.

Economic-focused strategies (such as the use of vendor permits in addition to consumer prescriptions) to combat AMR have been explored (see Coast, Smith, and Millar 1998). However, these strategies have not been reconsidered in a context where globalised e-commerce is normalised, let alone in the recent pandemic context in which health-related consumption has been exploited by financial scams (Kemp et al. 2021). Given that laws vary by jurisdiction, it has been suggested that ‘rogue’ pharmacy trade be the subject of a commercial (rather than pharmaceutical) crackdown (LegitScript 2016, 50). The means by which vendors register and purchase web domains (paying fees to hosting companies, engaging payment providers to handle transactions and so forth) create digital traces that could be monitored more closely to curtail unregulated pharmacy activity. However, the data sharing required here would, again, be at odds with the free-market drivers of the internet.

Blocking search results is another current strategy (Google 2021). However, the challenge for search companies and legitimate pharmacy providers is to redirect consumers on their information-seeking journeys—rather than seeking to halt them. There is evidence to suggest that searches for trending health news topics could be harnessed to provide timely health information to consumers. During a recent outbreak of AMR gonorrhoea in the UK, there was a significant correlation between search interest in the story, and increased clinic attendance (Smolarchuk et al. 2019). Significantly, this occurred organically, ahead of any specific partnerships between news media outlets, internet search providers, public health departments and health practitioners. This mirrors past examples, such as internet search during the swine influenza (H1N1 influenza) outbreak in 2009—patterns that mapped the spread of the virus well ahead of epidemiological data (Mayer-Schönberger and Cukier 2017)—and the increase in immunity-related Google searches at the beginning of the COVID-19 pandemic in 2020 (Davis 2022, 75). A more proactive stance from internet companies—not just silencing misinformation but amplifying relevant sources—could combat antimicrobial misinformation and potentially be harnessed to drive system and individual responses.

Because antimicrobials have been neglected by regulatory systems, it would be advantageous to disaggregate them from generalised ‘rogue’ drug imports (and the moral panics surrounding illicit substances) (see Australian Crime Intelligence Commission 2019) and gain a sense of the scale of the unregulated pharmacy trade for legal but dangerous potential reservoirs of antibiotics. In addition, it would be helpful to map the regulatory and governance context of nation states, and their role in constricting and/or enabling consumers (ie, health insurance and drug subsidy schemes, and DTC advertising restrictions). This could focus domestically on populations without access to public health systems (Smith et al. 2021), or internationally, vis-a-vis current burdens of AMR (Murray et al. 2022). These approaches would enable understanding and quantification of the gaps in current public health systems globally, that could push groups of consumers to engage with unregulated pharmacy, including specific cases where digital health literacies can be improved.

Designing for consumer diversity

Our research also indicates the importance of online consumption pathways that enable care and reduce harms for consumers: beyond mere consumer conveniences, we re-emphasise that the ‘grey areas’ of online pharmacy provide vital access for some groups (Paparini et al. 2018; Smith et al. 2021; Huang 2022). Crucial to establishing an AMR-specific focus, then, is to better understand consumer pathways, how pharmacy designs relate to these pathways, and to then advance novel ways to frame AMR while balancing consumer agency and safety. Establishing relevant databases of online dispensing (⇓ Australian Commission on Safety and Quality in Health Care 2021, 91), consumption and risk implications, can help inform communication tools and policy to promote regulation and harm reduction. This requires more public and more nuanced detail than currently provided in government reporting (Australian Crime Intelligence Commission 2019), which focuses largely on illicit substances.

Here, AMR-specific interests can draw from not only well-established cross-cultural medical anthropology perspectives on medicine (van der geest and van der Geest and Whyte 1989; Whyte, van der Geest, and Hardon 2002), but also from foundational cases from online pharmacy research. Online-sourced sildenafil (ie, Viagra) remains an instructional example of online pharmacy research (Armstrong, Schwartz, and Asch 1999; Eysenbach 1999) and is representative of some of the wider social changes associated with burgeoning connectivity and the rise of internet cultures (Fox and Ward 2006). The prospect of obtaining sildenafil online epitomises the promises, pitfalls and pastiche of unregulated pharmacy: stigmatisation yet discretion, recreational use, targeted online advertising, corporeal safety concerns (ie, fakes), cyber security risks (ie, phishing), and individual medical entrepreneurialism in a neoliberal public health context. By contrast, online-sourced antiretroviral treatment (ART) prophylaxes (ie, pre-exposure prophylaxis, or PrEP) demonstrate the roles of clinicians, community groups and online pharmacies in addressing shortfalls in healthcare systems (Davis and Flowers 2014; Paparini et al. 2018; Smith et al. 2021; Huang 2022).

While distinct, these examples demonstrate the complexity of consumer pathways, the ways in which social issues mediate consumption, and the cyborg-ian nature of modern engagements with pharmacy (Martin 2006; Pienaar et al. 2020; Race et al. 2017). Complicating any call for greater regulation is the potential for looser regulations to increase equity and ameliorate some of the risks associated with off-label use. In New Zealand, for example, the reclassification of sildenafil (from prescription-only to pharmacy-only) resulted in a significant decrease in border-control seizures, as online consumers (re)turned to community pharmacy (Gauld 2018). Relatedly, the permissibility of PrEP importation into Australia—jointly supported by the Therapeutic Goods Administration (allowing personal importation and approval therapies), clinicians (handling prescriptions), and community-based organisations and grassroots collectives (providing health promotion)—ensures that essential medication costs are more financially equitable for both individuals with and without access to health insurance (Smith et al. 2021, 189 187). Deregulation that leads to more open health communication and consumer-clinician discussion can be a pathway to greater public safety (Brijnath 2012, 298).

Rather than attempting—and likely failing—to combat agile e-commercial practices, retailers (with regulators) could seek to create informative digital environments that reintroduce originality to the highly derivative presentation style of the marketplace. An initial measure would be the establishment of a certification standard, clearer than the current QCPP accreditation used by Australian pharmacies. This has already been recommended to aid Australian consumers and prevent mistakes in pharmacy practice, where systems intended for the sale of unrestricted medications also offer restricted drugs (Hope and King 2020; Hope, Mayne, and King 2015). There is also potential to harness features of telemedicine to enhance pharmacy regulation, allowing reviews of antibiotic treatments by experts (Santos et al. 2019). Alternatively, or additionally, certification could emphasise the real—not abstracted—role of human pharmacists, using staff biographies to build trust (Qin et al. 2021). Current certifications (even on legitimate sites) focus on the pharmacy and render the pharmacist invisible.

Researching consumers and digital pharmacy

Research is needed to document how consumers use online pharmacies to procure, stockpile and share antibiotics. Online pharmacy is presently untethered from AMR communications, policymaking or agenda-setting and there have been calls for social research on these matters (Lu, Sheldenkar, and Lwin 2020; Tompson, Manderson, and Chandler 2021). It is important to understand how consumer practices, both online and offline, relate to what is known about antibiotic consumption (Kamiński, Łoniewski, and Marlicz 2019), what is made known by public health channels (Hansson and Brenthel 2022), and rates of resistance. Venhuis et al. (2016) use of Interpol data, and the UK’s interest in out-of-hours antibiotic prescribing during COVID-19 (Zhu et al. 2021) demonstrate the kind of data and intent required to understand the scale of under-regulated antibiotic circulation, and the various institutional and jurisdictional attitudes towards antibiotic importation.

It is also important to understand how individuals articulate their antibiotic use (Davis et al. 2020b). Unregulated antibiotic consumption might not be isolated but linked to practices of polypharmacy (Brijnath 2012). These concerns might relate to the willingness of e-pharmacies to group medicines as ‘packs’, and the ability of online communities to find and share workarounds for existing systems of medicine governance (Hope, Mayne, and King 2015; Howes-Mischel 2017). Polypharmacy is elevated by the diversity of information online, and the multitude of consumer pathways available. Importantly, this polypharmacy can occur across what are traditionally considered ‘human’ and ‘animal’ drug domains, with implications therefore for the value of ‘One Health’ (Kahn 2016; Ticktin 2014) approaches to AMR. Thus, there is a need to better understand who digital pharmacy retailers are (Fittler et al. 2013; Tompson, Manderson, and Chandler 2021). Such enquiries could build on the subcultural ideologies (Howes-Mischel 2017) and aesthetic motivations (Reddy et al. 2021) already identified while also reflecting on relationships between pharmaceuticals and identity (Fox and Ward 2006; Martin 2006; Pienaar et al. 2020). Researchers could also draw connections between the fragmented aspects of online pharmacy marketplaces, and anthropological arguments for pastiche within the fragmented self (Wolputte 2004).

Expanding on our own ethnographic approach, medical humanities research could conduct co-research with consumer, such as ‘media go-along’ (Jørgensen 2016) methods, to gain insight into how they interpret and interact with online pharmacy environments (including information, images and certifications) and to unpack the symbolic meanings associated with medicines in everyday life (van der Geest and Whyte 1989; Chandler, Hutchinson, and Hutchison 2016, 12–13; Jamie and Sharples 2020). These approaches could be supported by further digital-ethnographic reviews of websites and smartphone applications (Dieter et al. 2019), especially if these approaches extend beyond the language (English only) limitations of this paper. Such approaches would elucidate the logistical operations and semantic and semiotic intentions of unregulated pharmacy platforms, vis-a-vis legal and clinical guidelines (MacLean and Hatcher 2019). Engaging human participants in tandem with visual media and digital objects can help form an evidence base for interventions and information campaigns (Irwin 2022), and would be novel in an Australian context, where humanities approaches to medicines are promising but nascent (Werder and Holland 2019).

The ‘pastiche medicine’ frame is also an important contribution to AMR prevention and critical scholarship on digital pharmacy. Pastiche medicine captures the lived experience of digital pharmacy, as it borrows the imprimatur of biomedical knowledge and combines it with the expansion of consumer assembled healthcare. These developments might be challenges and opportunities for AMR prevention, especially given the importance of global patterns of inequity (Kirchhelle et al. 2020). Digital pharmacy access might increase the use of antimicrobials when they are not needed. However, consumers using digital pharmacy to source antibiotics might be more easily reached in these environments, and can therefore be assisted to reduce health risks. Given how COVID-19 accelerated and normalised digital health, increased public policy engagement is required regarding the ways in which digital pharmacies curate pastiche-like mixes of biomedicine and consumption. We also argue that critical scholarship on digital pharmacy can be advanced by incorporating analyses of antimicrobials. Similar to the ‘mimetic’ and ‘parody’ performances of some so-called ‘traditional’ medicines (Langford 1999) and metaphors in pharmaceutical advertising (Delbaere 2013), pastiche medicine borrows and dismembers biomedical expertise, but it also trades in the healing possibility of medicines to gain ontological weight. The antimicrobial example we explore here speaks to the wider digital pharmacy landscape by providing deeper and more nuanced understanding of the digitally engaged patient, and a cognisance of polypharmacy that includes how consumers might seek to manage infections or perceived health risks.

In antibiotic digital pharmacy we find a blending of information, genres and digital formats, befitting the term ‘pastiche medicine’. For AMR prevention, pastiche is problematic, rendering antibiotics unremarkable, inexpensive and readily available. In a pastiche environment, antimicrobials take on a quotidian quality, presented alongside unrestricted drugs, vitamins and other non-medical goods in ways that emphasise consumer self-assembly. The threat posed by AMR, alongside other health crises, will only accelerate digital health in the future. In these circumstances, the curation of information, the knowledge of experts, risk management advice and of course, direct access to pharmaceuticals, are ongoing issues. Public policy, on AMR prevention and beyond, will need to catch hold of these currents and establish methods for protecting the health of consumers.